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$&S. NAVY DEPARTMENT 

Burbaxj op Medicine and ^urqery. 



Naval Medic 



al Schools 



FRANCE AND 



AND. 




REPORTED TO THE BL 



RICHARD 



SURGERY 



WASHINGTON: 

GOVERNMENT PRINTING OFFICE 
1876. 



U. S. NAVY DEPARTMENT 

Bureau of Medicine and Surgery. 



aval Medical Schools '•'■■■" 



OF 

FRANCE AND ENGLAND, 

WITH 



P 



BSERYATIONS ON THE 



Naval Hospitals of T 



ospitals of Toulon. 




REPORTED TO THE BUREAU OF MEDICINE AND SURGERY, 

BY 

RICHARD C. DEAN. 

MEDICAL INSPECTOR UNITED STATES NAVY. 



WASHINGTON: 

GOVERNMENT PRINTING OFFICE 
I876. 



m* 1 






M 






o 



Navy Department, 
Bureau of Medicine and Surgery, 

November 10, 1876. 
The following reports on the " Naval Medical Schools of France 
and England, with observations on the Naval Hospitals of Toulon," 
are the result of an inspection of these establishments by Medical 
Inspector Richard C. Dean, United States Navy, under authority 
from the honorable Secretary of the Navy and instructions from this 
Bureau. 

J. BEALE, 
Surgeon - General, U. S. Na vy. 



CONTENTS. 



Pa s e < 

1. Letter of instruction from the Bureau of Medicine and Surgery 3 

2. Letter from the honorable Secretary of the Navy 4 

3. Letter from Medical Inspector Richard C. Dean, United States Navy, trans- 

mitting his report to the Bureau of Medicine and Surgery „ 4 

4. Naval medical schools of France 9 

5. Naval medical school, Toulon „ 27 

6. Naval hospitals, Toulon 35 

7. Naval hospital of Saint Mandrier 50 

8. Education of medical officers for the public service in England 55 

(a) Letter of transmission of Medical Inspector Dean, United States Navy; (b) 

Organization; (c) Faculty; (d) System of instruction; (e) Museum; (f) Libraries ; 
(g) Examination of Candidates. 



ILLUSTRATIONS 



Plate I. Original Medical School of France, (Rochefort.) 

II. Proposed Naval Hospital, Toulon. 

III. Naval Hospital, Toulon, (basement.) 

IV. Naval Hospital, Toulon, (second floor. v 
V. Naval Hospital, Brest. 

VI. Royal Victoria Hospital, Netley. 

VII. Royal Victoria Hospital, (basement.) 

VIII. Royal Victoria Hospital, (first floor.) 

IX. Royal Victoria Hospital, (second floor.) 



NAVAL MEDICAL SCHOOLS 



OF 



FRANCE AND ENGLAND, 



I N 



Navy Department, 
Bureau of Medicine and Surgery. 

June 19, 1874. 

Sir : With the view of improving the Medical Department of the 
Navy, it is deemed desirable to obtain accurate and detailed infor- 
mation relative to the military medical schools and hospitals of the 
most advanced nations of Europe. Your approaching cruise in Eu- 
ropean waters will afford you many facilities for visiting those insti- 
tutions, and observing their organization, methods of management,, 
and general working. 

Relying on your scientific and general intelligence, the bureau has 
to direct that you will avail yourself of every opportunity to make a 
careful inspection of these establishments, both in England and on 
the Continent, and to collect all the information your time will allow 
on every point of interest connected with them. When performing, 
this duty, you will be pleased, in the case of the schools, to investi- 
gate the methods of instruction pursued, and, in that of hospitals, to 
consider the important subjects of ventilation, heating, and drainage 
as special objects of study. Copies of curricula of studies at the 
former, and of regulations for the administration of the service of the 
latter, would greatly contribute to the attainment of the purposes 
contemplated by the bureau in giving you these instructions. You 
will be pleased, at such times as may be most convenient, to commu- 
nicate the results of your observations and inquiries to this bureau. 

Very respectfully, 

J. BEALE, 

Surgeon- General, United States Navy.. 

Medical Inspector Richard C. Dean, U. S. N., 

Washington, D. C. 



4 NAVAL MEDICAL SCHOOLS OF FRANCE AND ENGLAND. 

Navy Department, 
Washington, June 20, 1874. 

Sir : I herewith inclose a communication addressed to you, under 
•date of the 19th instant, by the chief of the Bureau of Medicine, and 
■Surgery, inviting your attention to several points respecting military 
medical schools and hospitals, and asking you to report the result of 
such observations as you may make on the subject, in pursuance 
•of special orders received, to him. You will please make all your 
reports in relation to hospitals, &c, in Europe, to the Bureau of 
Medicine and Surgery. 

I also inclose a general letter, addressed by the Department of 

State to the ministers and consuls of the United States in Europe, 

asking them to facilitate you in executing the special duty with which 

you are intrusted. 

Very respectfully, 

GEO. M. ROBESON, 

Secretary of the Navy. 

Medical Inspector Richard C. Dean, U. S. N., 

Washington, D. C. 



Toulon, France, March 1, 1875. 
Sir : I have the honor to state that, for the purpose of carrying out 
the preceding instructions in regard to visiting the naval and military 
medical schools and hospitals of Europe, I requested and received, 
from Rear-Admiral Case, commanding the European squadron, the 
authority conveyed in the following order: 

"United States Steamer Franklin, (1st rate,) 

"Flag-ship, European Station, 

"Naples, Italy, November 18, 1874. 
"Sir: In compliance with your request under date of the 15 th instant, 
for orders to visit the naval and military hospitals of Italy and France, 
under your general instructions from the Navy Department, to visit 



NAVAL MEDICAL SCHOOLS OF FRANCE AND ENGLAND. & 

and report on the hospitals of Europe, and in obedience to its instruc- 
tions to me, to give you orders for that purpose when necessary, you 
will proceed to visit the hospitals indicated, and you will arrange 
with Captain English to rejoin the Congress when that duty is com- 
pleted. 

" Respectfully, 

"A. LUDLOW CASE, 

" Commander-in- Chief. 
"Medical Inspector R. C. Dean, U. S. N., 

" United States Steamer Congress ; European Station." 

The appearance of a malignant fever on the Congress at this time 
made it inexpedient for me to leave the ship, and, other causes of pre- 
vention occurring, it was not until some months afterward that I felt 
iustified in absenting myself from the vessel. Having been informed 
by Admiral Jaureguiberry, the prefet maritime commanding the port 
of Toulon, that it would be impossible for me to pursue my investi- 
gations to advantage without being duly empowered so to do by the 
minister of the marine, I proceeded to Paris, and, through the kind- 
ness of Mr. Washburne, obtained the necessary permission to visit 
all the naval medical establishments of France, embracing those of 
Cherbourg, Brest, L' Orient, Rochefort, and Toulon. 

I selected the latter place to begin my duties, as being the great 
Mediterranean military port and naval depot of France, and as hav- 
ing had long established within its impregnable fortifications a naval 
medical school, a naval and a military hospital, and, in its vicinity, 
the immense receiving naval hospital of Saint Mandrier, for invalids 
returning from distant squadrons, and from the colonies of Algeria, 
Senegal, Cochin-China, and New Caledonia. 

On my return to Toulon, I learned with regret that the admiral 
who had received me so courteously before was suffering from a dan- 
gerous attack of pneumonia, and was not, for the time being, on duty. 
This officer is of a very high degree of intelligence, and himself feels 
a deep interest in hospitals and all means for the amelioration of the 



€ NAVAL MEDICAL SCHOOLS OF FRANCE AND ENGLAND. 

condition of the sick in the naval service. I had found him on the 
occasion of my former visit very well informed on the subject and 
acquainted with the principles of modern hospital construction 
adopted in America, which he strongly favored, and had advocated 
in connection with the project of erecting a new naval hospital at 
Toulon. I was sorry to lose the benefit of his experience and influ- 
ence, but was informed by Contre-Amiral Lage, the acting prefet, 
that dispatches had been received from the minister in regard to my 
visit, and that every facility would be afforded me to examine all the 
medical establishments of the port. 

I was cordially received by Dr. Arlaud, the director of the school, 
and by the staff of professors and medical officers attached to the 
institution, whom I found also apprised of the object of my visit 
through dispatches from Paris. 

These gentlemen all tendered me their services of assistance, and 
invited me to be present at their lectures, and to visit the hospital at 
all times I should desire. I have accordingly entered upon a daily 
attendance at the hospital at the hours of the lectures and demonstra- 
tions, and of the visits to the patients in the wards; believing this to 
be the best plan of acquainting myself with the method of instruction 
and management. 

I have also been allowed the privilege of using the extensive library 
of the school, and of examining the archives of the institution, which 
I have found to be valuable and interesting sources of information. 

I have the honor to transmit herewith the accompanying reports, 
which are designed only as preliminary to a final and general report 
of the result of my observations. 
Very respectfully, 

RICHARD C. DEAN, 
Medical Inspector, United States Navy. 

Surgeon-General Joseph Beale, U. S. N., 

Chief of the Bureau of Medicine and Surgery, 

Navy Department. 



NAVAL MEDICAL SCHOOLS 



OF 



FRANCE. 



NAVAL MEDICAL SCHOOLS OF FRANCE. 



For more than a century the government of France has deemed 
it the interest of the state to superintend the education of medical 
officers for the naval service. During the whole of that period schools 
have been maintained in which the special training required for this 
purpose could be given to young men who were candidates for ap- 
pointment or promotion in the medical corps of the navy. This 
system, now held in such high repute, seems to have been adopted 
slowly, gradually, and even reluctantly at first, and to have been 
rather an outgrowth from the requirements of the service than a pre- 
conceived plan. From its intimate connection with the main subject 
of this report, and in view of a similar need presenting itself more 
and more every year in our own country, it may be desirable to give 
a brief sketch of the origin and establishment of the present method 
of preparing medical officers lor the navy in France. And, for the 
encouragement of any who may some day undertake to secure for 
our service so great an advantage, let it be observed that here it was 
only achieved after many disappointments, repeated refusals, and 
much indifference from those high in authority. Fortunately the 
project found an advocate whose zeal and courage accepted no de- 
feats, and who, undismayed by the failure of his first efforts, pressed 
patiently on until he won complete success. 

Monsieur Dupuy, having been appointed in 1715 principal surgeon 
at the port of Rochefort, Tound manifold complaints made of the 
ignorance and inefficiency of the surgeons embarked on the ships. 
These he soon ascertained to be well founded, and forthwith ad- 
dressed a letter to the minister, in which he suggested the inaugura- 



10 NAVAL MEDICAL SCHOOLS OF FRANCE. 

tion, at the hospital of Rochefort, of a system of instruction for 
young men to qualify them for the duties of naval surgeons. No 
action was taken on this recommendation, either at this time or upon 
a repetition of it, later in the same year. In 1716, M. Dupuy 
submitted anew farther representations on the subject, stating the 
impossibility of procuring otherwise surgeons who should be capable 
and properly instructed. This request met with no better success 
than the others. In 171 7, a fourth time, the attention of the minister 
was called to the matter, but without avail. In 17 19, however, per- 
mission was given to make demonstrations of anatomy in the hospi- 
tal, and of chemistry in the laboratory ; but no assistance was given, 
either in teachers or money. 

In spite of all the difficulties he encountered, M. Dupuy continued 
to urge the opening of a school of medicine and surgery, and, in 1720, 
he went in person to Paris, and pleaded his cause before the naval 
council and the high admiral of France. He represented that, by 
connecting a school of medicine with the hospital itself, students 
could become acquainted in advance with the various diseases and 
injuries received by mariners, in all parts of the globe, in war and 
peace, and that this was a precious source of instruction which it 
would be criminal not to utilize. He also argued that, by placing 
the school in the midst of a maritime population, young men would 
be attracted to it who were already familiar with the manners and 
customs of sailors, and who would not feel the same repugnance to 
scenes in a life so rude and perilous as those who were suddenly in- 
troduced to it as strangers. His able advocacy finally prevailed, and 
he obtained the authority he had so long sought. 

On his return, however, he could only procure from the comman- 
dant at Rochefort, for his use, one room, which was very dark and 
inconvenient, and which was partly filled with invalids. A plan sub- 
mitted to the minister for the erection of a suitable building was not 
adopted for some time, but was at length approved in 1721, and one 
year later the structure was finished. (See Plate 1.) 



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"■■^1 T 







NAVAL MEDICAL SCHOOLS OF FRANCE. 11 

Everything being at last in readiness, in 1722 the first naval medi- 
cal school of France was formally opened, in the presence of the 
naval and the civil prefect, and a large number of naval officers of 
all grades. So immediate and complete was its success that the 
minister wrote to Mr. Dupuy to express to him how much the King 
was gratified with his zeal for the good of the service, and with the 
wisdom of his views for perfecting the institution he had created. 
He also gave him liberty to do anything he should believe advan- 
tageous for the improvement of an establishment which His Majesty 
intended to favor with his particular assistance. Subsequently, Mr. 
Dupuy was recompensed for his long and valuable service by having 
conferred on him a title of nobility. Thus it appears that it was 
chiefly to the untiring efforts of one individual that France is indebted 
for an institution which has, without doubt, kept her marine supplied 
with medical officers of the highest order of intelligence and efficiency. 

So acceptable were the results of the new system to the govern- 
ment that it was within a few years extended by the foundation of 
additional schools at Toulon and Brest. The former was established 
in 1725 and the latter in 1731 ; and since that time, during a period 
of more than a hundred years, these three schools have continued to 
enjoy the confidence and support of the nation under every form of 
government. 

A multitude of regulations and orders of the olden time have been 
preserved among the archives of the school at Toulon, some of 
which are extremely curious, in regard to the management of the 
schools; but I have not been able to find any law establishing them 
previous to a royal ordonnance, issued in 1768, which is as follows. 
The diction is rather antiquated, and, according to present notions, 
scarcely grammatical, but the intent is clear: 

"De par le Roi." 

"II sera choisi, dans l'interieure, ou a portee de l'hopital de 
chacun des ports de Brest, Toulon et Rochefort, les lieux com- 



12 NAVAL MEDICAL SCHOOLS OF FRANCE. 

modes et convenables pour y etablir les ecoles de medecine et de 

chirurgie navale, lesquels ne pourront etre, sous quelque pretexte 

que ce soit, pris pour d'autres usages. 

" Du Premier Mars 1768. 

Signe, " LOUIS." 

During all the confusion and overthrow of established institutions 
in the Reign of Terror, and during the days of the republic, these 
schools remained undisturbed, and were continued by a special de- 
cree of "17 Nivose, An IX." 

It is an interesting fact, which may be mentioned here, that the 
medical corps of the navy of France owe to the spirit of equality 
which prevailed at this epoch the concession of a right which they 
had long sued for in vain, that of being assimilated in all respects 
with the surgeons of the army. Perhaps never in any other place 
than before this decree appeared with more appropriateness the no- 
torious motto of the republic. 

"liberte, egalite, fraternite." 
"12 Messidor, l'an troisieme de la Republique Francaise, une et 
indivisible. (30 June, 1795.) 

" Les officiers de sante de la marine seront assimiles aux officiers 
de sante des armees de terre pour le classement et le traitement. II 
en sera de raeme pour les accessoires, les indemnites, les conges, les 
retraites, et autres attributions. 

Signe, " CAMBACERES, 

"President. 
" Roux, Verron, Rabaut, Marne, Comite." 

How simply and easily such a law would have settled all the con- 
tentions which not long since disturbed the medical corps of our 
Navy! 

No doubt, many a perplexed candidate before the naval medical 
board of a certain other republic would be grateful for such a priv- 
ilege as was accorded by this all-equalizing time in the following de- 
cree in regard to the examinations for assistant surgeons: 



NAVAL MEDICAL SCHOOLS OF FRANCE. 
" LIBERTE, EGALITE, FRATERNITE." 



13 



"19 Pluviose, An VI de la Republique Francaise, une et indivi- 
sible. 

"Le concours pour toutes les classes aura lieu en public et de vive 
voix: les questions seront faites par ecrit, et tirees au sort. La ques- 
tion tiree, les juges ne pourront point interrompre le candidat, ni lui 
proposer aucune espece de questions incidentes." 

Another curiosity of this time is the following table for sum- 
ming the qualifications of candidates, given as a model in the same 
decree: 



Nom du 
individu. 


Anatomic 


Chirurgie ope- 
ratoire. 


Pathologie 
medicalc 


Pathologie 
chirurgicalc 


Hygiene na- 
valc 


Pierre ... 


Tresbien .. 
Passable ... 


Bien. .. 


Bien .... 
Mai 


Faible 

Tres mal . . . 


Bon. 


Paul 


Bien 


Bien. 








Nom du 
individu. 


Histoire na- 
turelle. 


Accouchements. 


Chimic 


Total. 


Decision. 


Pierre ... 


Passable ... 
Faible 


Bien 


Mai 

Passable . 


Bien 

Mediocre... 


Acceptc 
Rejetc 


Paul 


Faible. 



These medical schools for the navy were equally cherished by both 
the first and second empires, and the records of these periods contain 
many expressions of the highest commendation toward institutions 
which were considered to render valuable service to the state. 

The commission of the budget in 1836-37 reported to the Cham- 
ber of Deputies that " the organization of the medical schools of the 
navy, which exist in our ports, invariably tends to produce that high 
capacity and tried courage, the influence of which, however indirect, 
is so powerful upon the success of our naval operations. Above all, 
it is important to have medical officers who deserve confidence, and 
who know how to command it — men of science and of action, skillful 



14 NAVAL MEDICAL SCHOOLS OF FRANCE. 

and firm in the day of battle as well as among the victims of deadly 
epidemics, able to forward the advance of science by study and ob- 
servation in the distant countries where they are called to serve, and 
to add still more to the influence of the name of France, through 
the reputation for humanity and disinterestedness which their prede- 
cessors have so justly acquired." — (Moniteur, 15 Mai 1836.) 

In 1 84 1, the minister of the marine expressed himself thus on the 
same subject: "The medical corps has ever sought to distinguish 
itself solely by superior talent and eminent service. It numbers many 
men, profoundly instructed, honoring science by the manner in which 
they cultivate it, and full of zeal for the accomplishment of their 
duties toward humanity. The schools of medicine at Brest, Roche- 
fort, and Toulon enjoy also a high reputation, justly merited. There, 
learned professors, who are no other than officers of the corps, give 
to numerous pupils instruction which is not disclaimed by the most 
renowned of the faculties of Paris." 

During a discussion in the Chamber of Peers in 1847, several illus- 
trious members spoke in terms of eulogy of these schools, and the 
president, M. Mesnard, made the following remarks : " Such is the 
organization of the corps which performs its duties at Toulon, Brest, 
and Rochefort. The instruction is given by professors, who, bear- 
ing the title of ' docteur,' are not those who honor it least. The 
pupils leave the chair of the professor to go, under his conduct, to 
the bedside of the sick, passing thus from the lesson to its application 
on a vast scale." 

The same orator, in advocating the allowance for the expenses 
incurred by assistant surgeons in obtaining the degree of doctor of 
medicine, exclaimed, "What, the cost of the diplomas! It has been 
paid ten times over. It has been paid with a price no other persons 
will ever pay. It has been paid by services rendered to the country 
in the midst of hardships, in perils of the sea, and of far-distant voy- 
agings. They have been paid by sacrifices the state ought never to 
forget." 



NAVAL MEDICAL SCHOOLS OF FRANCE. 15 

Many of the most distinguished names in the annals of French 
medicine are to be found on the rolls of these schools, and men, who 
afterward threw a lustre on the profession of France and of the 
world, received here their earliest education and experience. 

Larrey, previous to his brilliant career in the army, was examined 
for admission into the navy at Brest, and served on board the Vigi- 
lante and other ships for nearly ten years, from 1777 to 1788. 

Broussais was also examined at Brest in 1794, and served on board 
the Renommee, L'Hirondelle, and Bayonne. 

Recamier was examined at Toulon in 1795, and served on board 
the Qa Ira during the sanguinary engagement with the English 
fleet, in which 400 men were killed and wounded on. that transport, 
including the senior surgeon. 

Numerous reorganizations of the schools have been made from 
time to time, involving various changes in the mode of management. 
The last regulations on the subject were issued by the minister of the 
marine in 1866, and are the ones in accordance with which the teach- 
ing is now conducted. But more recently, in 1873, a commission has 
been in session in Paris for the purpose of making further modifications 
and improvements. These have not yet been adopted by the gov- 
ernment, but have been kindly placed at my disposal by Dr. Arlaud, 
who was a member of the commission, and are embodied in the 
following account of the method of admission, instruction, and ex- 
amination in the medical corps of the navy. 

The naval medical schools established by the department of the 
marine in the ports of France are designed for the education of 
medical officers and pharmaceutists for service in the navy and in 
the colonies. The instruction is given by medical directors, by phy- 
sicians and pharmaceutists-in-chief, by surgeon and pharmaceutist 
professors, and other officers of the medical corps belonging to the 
higher grades. Of these, the senior officers are permanently at- 
tached to the schools, but are assisted by members of the junior 
grades known as " agreges," or " fellows," whose duties are tempo- 



10 NAVAL MEDICAL SCHOOLS OF FRANCE. 

rary, and continue for three years only at a time. While the latter 
are engaged in this special duty, they are exempted from orders to sea. 

In each school there are — 

An amphitheater for dissections ; 

An amphitheater for lectures on medicine and surgery; 

An amphitheater for lectures on chemistry ; 

A library; 

A botanical garden ; 

A museum of natural history, pathology, and anatomy. 

These rooms, with their appendages, constitute the medical school 
proper; but the wards of the naval hospitals are also used by the pro- 
fessors for clinical instruction. 

No students are received into these schools unless they are "bach- 
elors of letters " and " bachelors of sciences," and are at least eight- 
een years of age. They must also be citizens of France. A physical 
examination precedes the admission, which ascertains that the candi- 
date has integrity of the special senses, and of all the organic func- 
tions ; that he is vaccinated, and has no specific disease. Students 
are subjected to a certain discipline, and to a scale of punishments 
ending in dismission. Expelled from one school, they are excluded 
from all the others, and the naval career is closed against them. At- 
tendance on the lectures and clinics is obligatory, and unjustifiable 
absence from them is followed by dismissal. 

All the members of each school are classified in two divisions. 
Those of the first year form the second division, and all the others 
form the first division. Promotion from the first to the second divis- 
ion is only obtainable by passing an examination at the end of the 
year. Those who fail to pass the examination are retained in the 
second division, and, in case of a second failure, are dismissed. 

The curriculum of studies is as follows : 
i. Legal and administrative medicine. 

2. Clinical medicine; medical pathology. 

3. Materia medica and therapeutics; toxicology. 



NAVAL MEDICAL SCHOOLS OF FRANCE. 17 

4. General and naval hygiene. 

5. Cliriical surgery; surgical pathology. 

6. Operative surgery. 

7. Anatomy and physiology. 

8. Obstetrics, diseases of women and children. 

9. Chemistry. 

10. Pharmacy and medical physics. 

11. Natural history, (medical;) pharmacology. 

12. Descriptive anatomy. 

13. General pathology and semeiology. 

14. Minor surgery; apparatus and bandaging. 

15. Extemporaneous pharmacy; chemical manipulations. 

The annual course is divided into two sessions, one in winter and 
one in summer. Part of the above branches are taught in one ses- 
sion, and the remainder during the other. Every subject is lectured 
on three times a week, and every professor completes his course once 
in two years. 

Every professor prepares, for the director of the school, notes in 
regard to the students and assistant surgeons who attend his lectures, 
to be referred to at the examinations. Assistant surgeons remain 
under instruction for two years after appointment, and are only sent 
to sea during six months of that time. After two years passed in 
that grade, they are granted a leave of absence, on full pay, for the 
purpose of presenting themselves for the degree of "doctor of med- 
icine" before one of the "faculties" of France empowered to grant 
diplomas. This six months' leave can neither be extended nor re- 
newed, and during its continuance a certificate must be sent every 
month to the director of the school to which they belong, showing 
that they are engaged in pursuing the object for which the leave was 
granted. This certificate is given by the secretary, and viseed by 
the dean of the faculty. 

For all the expenses incurred in procuring this degree, they are 
re-imbursed from the funds of the department of the navy, upon the 

2 N 



18 NAVAL MEDICAL SCHOOLS OF FKANCE. 

production of the diploma. In return for the above privileges,, of 
receiving a medical education without cost, and of having the ex- 
penses of procuring a degree in medicine defrayed by the government, 
they are required to engage themselves to remain in the service ten 
years, or to restore to the department the amount of the latter expend- 
iture. The written contract to this effect is sent to the legal agent 
of the treasury, who, if necessary, compels them, by process of law, 
to refund the sum. 

EXAMINATIONS FOR ADMISSION AND PROMOTION 
IN THE MEDICAL CORPS. 

The examinations for appointment as assistant surgeon in the navy, 
or for promotion to a higher grade, are conducted with great formal- 
ity, and in a manner essentially different from that in use in the United 
States. Though a very complex method, it is a very interesting one, 
and, as it seems to me, could scarcely have been devised out of France, 
characterized, as it is, by the remarkable ingenuity and suspiciousness 
which are eminent traits of the French people. 

It could not be more impartial, even if the object of the ordeal 
were to determine the life or death of the candidate. Unfairness is 
impossible, both examiners and candidate being strangely discon- 
nected from a proceeding, apparently directed by an unseen hand, 
which only invokes their assistance as instruments. 

The medical examining board, or "jury of competition," as it is 
most appropriately called in France, is composed of four members, 
and an alternate or substitute, the junior member acting as secretary. 
The four members are — 

i. A medical director, who presides; 

2. A " physician-in-chief," who is a professor in the school where 
the examination is held; 

3. Two professors, of whom one belongs to each of the other two 
schools. 



NAVAL MEDICAL SCHOOLS OF FRANCE. 19 

The alternate is a professor in the school where the examination 
is held. 

The selection of professors who are to assemble as a medicaljury 
in any school is made in the following manner: On the first of Sep- 
tember of each year, at a meeting of all the professors of each school, 
lots are drawn to determine the names of the two. professors who are 
to go to the two other schools ; the name of the one who is to be a 
member of the jury in his own school; and, finally, the name of the 
alternate. The director of each school sends the names so desig- 
nated to the prefet maritime, who transmits them to the minister ol 
marine. The minister orders the members to the different schools 
in such a way as to secure as fair and impartial a jury as possible. 
As an evidence of the extreme precaution taken in this regard, it is 
worthy of note that if a member of a jury is any relative or^con 
nection of a candidate, even to the fourth remove, he cannot take 
part in the examination of that candidate, but must yield his place 
to the alternate. 

The examination for the appointment of assistant surgeons is on 
the following subjects : 

i . Anatomy / 

t, , , v • Non- 
performance of a dissection ^ 

2. Pharmacology ) 

Extemporaneous pharmacy V 

3. Minor surgery > ) 

Application of apparatus and bandages I 

4. General pathology and semeiology Written. 

The examination for promotion to the grade of surgeon of the 
second class comprises — 

1. Anatomy and physiology Oral. 

2. Materia medica and therapeutics Oral. 



20 NAVAL MEDICAL SCHOOLS OF FEANCE. 

3. External pathology 1 

Operative surgery v. Oral. 

Obstetrics \ 

4. Internal pathology ~) 

Hygiene , J> Written. 

Legal medicine \ 

For promotion to the grade of surgeon of the first class, the exam- 
ination is on the following subjects: 

1 . Physiology Oral. 

2. Clininal medicine Oral. 

3. Operative surgery j 

Obstetrics 1 

> Oral. 

Performance of one surgical and one obstetrical opera- 1 

tion I 

4. Naval hygiene J 

Pathology ■ . . y Written. 

A report on medical jurisprudence \ 



This report must be written and placed in a sealed envelope in 
two hours after the commencement of the session. 

QUESTIONS. 

Lists of questions are prepared, in secret conference, by the juries 
at each school, and are sent to Paris to the minister of the marine. 
All the questions from all the schools are placed together, and a com- 
mission composed of the superior medical council and the director of 
the "Archives of Naval Medicine " makes a selection from the num- 
ber. The questions chosen are placed in closed envelopes, sealed, 
signed on their folds by the members of the commission, and addressed 
by the minister of the marine to the prefet maritime of the port where 
the examination is to take place. The prefet transmits them to the 
president of the jury after it has assembled. When the examinations 
are concluded, the questions which have not been used are returned 



NAVAL MEDICAL SCHOOLS OF FRANCE. 2V 

to the minister of the marine without the seals of the envelopes con- 
taining them being broken. 

On my expressing surprise at the suspicion of the good faith of 
every one concerned in the preparation and custody of these ques- 
tions, I was informed, in a reply more idiomatic than satisfactory, 
that "the thought did not come to any person to believe that the 
secret would not be guarded as to the tenor of the questions chosen, 
but a secret could be surprised; and, in a word, a secret being able 
to be violated, this possibility made it necessary to adopt a method of 
keeping it that should be inattackable." 

MANNER OF. CONDUCTING THE EXAMINATIONS. 

Before the opening of the examination, the jury, in secret session,, 
arranges the list of competitors, which is posted in a conspicuous 
place. The examinations are held in public. The commander-in- 
chief of the station presides at the opening of the first session, and the 
secretary reads the order convening the jury, and calls the roll of 
the candidates. The names of those present are placed in an urn. 
If the number is large, the lot determines which ones shall be exam- 
ined in the first series, and the names of these are again placed in the 
urn. 

The president publicly breaks the envelope containing all the ques- 
tions. Those for the different grades are found within, placed in 
special envelopes. The envelope containing the questions intended 
for the first examination is next broken. Every question, sealed, 
bears a number. The president places in another urn as many balls 
as there are questions sent by the minister, each ball bearing a num- 
ber corresponding to that on a question. A person designated by 
the president draws from the urn the name of the first candidate to 
be heard. All the other candidates are immediately conducted to an 
isolated apartment, and locked in by a member of the jury, whence 
they are successively called as the lot determines the turn of each. 
One of the balls, Containing a number corresponding to that on one 



'22 NAVAL MEDICAL SCHOOLS OF FRANCE. 

of the questions, is then drawn from the urn. The president breaks 
the seal of the envelope bearing the same number, and reads aloud 
the question which it contains, which is then handed to the candi- 
date. This same question must now be submitted to all the candi- 
dates, each in his turn; no communication being allowed between 
them. By the same method, a new question is drawn at every fol- 
lowing session. Every remark, every sign of approbation or disap- 
probation, is prohibited to the members of the jury during the exam- 
ination, which must be conducted in silence by the jury, excepting 
that the president may recall the candidate to the question if he 
should wander from it in his reply. 

The time allowed each candidate to answer each question is : 

For the grade of assistant surgeon, one-half hour, after ten minutes 
of reflection ; 

, For the grade of surgeon of the second class, one-half hour, after 
ten minutes of reflection ; 

For the grade of surgeon of the first class, three-quarters of an 
hour, after fifteen minutes of reflection ; 

For appointment as "fellow," {agregc,) one hour, after half "an 
hour of reflection ; 

For appointment as professor, one hour, after half an hour of reflec- 
tion. 

The candidates, if they wish, can retire into a room adjacent to the 
examination-room while they consider their answers ; but they must 
be isolated and kept under surveillance. It is forbidden them, under 
penalty of exclusion from the examination, to make use of any books 
or papers of reference; but they have the privilege of making memo- 
randa to guide them in their replies. 

During the whole of the session, the candidates remain without any 
communication, and under the observation of a professor, who coun- 
ter signs all the written answers, and places them in sealed envelopes, 
to be read aloud by the candidate on the following day in public. 



NAVAL MEDICAL SCHOOLS OF FRANCE. 23 

They are then again placed in sealed envelopes, and reviewed by 
the jury in private session. 

Candidates who have been partially examined are recalled at an 
interval of forty-eight hours to answer another question. Every can- 
didate who fails to answer a question is excluded from further exam- 
ination. When any answer seems insufficient, the president calls the 
attention of the jury to it, and it is decided by vote whether it shall 
be received. If it is declared inadmissible, this decision is announced, 
and is entered by the secretary on the records. 

Immediately after having heard the last candidate in each series, 
the president gives to each member of the board a list of the candi- 
dates examined, arranged in alphabetical order. Each member 
writes after the name of every candidate a number indicating his 
estimates of the answers given. Zero signifies total failure; 5, bad; 
10, tolerable; 15, good; and 20, very good. Each paper is then folded 
and sealed by the member voting, and marked with the grade of the 
candidate. The papers for each grade are then counted by the pres- 
ident and placed in a common envelope, which is indorsed with the 
signatures, of ail the members voting, and deposited in a secure recep- 
tacle. 

After the examinations for all the grades have been concluded, the 
papers are opened in the presence of the prefet maritime, (com- 
mander-in-chief,) commencing with those of the highest grade. All 
the professors who have voted are present at the opening. The pre- 
fet designates two among them to scrutinize the votes. Each one 
of the two prepares a list in alphabetical order of all the competitors. 
The president breaks the envelopes of the different bulletins relating 
to each grade, and reads them aloud, indicating the numbers attached 
to each name. After the enrollment of the votes on the lists of the 
two scrutinizers, these lists are compared and verified. These gen- 
eral lists are then signed by all the members of the jury and counter- 
signed by the prefet maritime. One of them is transmitted to the 
minister of the marine, together with the bulletins of the votes, and 



24: NAVAL MEDICAL SCHOOLS OF FRANCE. 

the other is attached to the record of the examination and deposited 
in the archives of the medical council. 

A "superior commission," appointed by the minister of the marine, 
is charged with the final classification of the candidates borne on the 
general lists forwarded from all the schools. This commission is com- 
posed of — 

i. A vice-admiral, member of the board of admiralty; 

2. The members of the superior medical council; 

3. The chief of the bureau of medical administration. 

The candidates are arranged by the commission according to the 
aggregates of the numbers they have received. No candidate is 
considered admissible unless he has obtained at least an aggregate of 
200. In case of equality, age determines precedence. After the 
opening of the bulletins containing the votes, the commission sends 
the report of its proceedings to the minister of the marine, together 
with the various papers which have been used in arriving at the final 
classification of the candidates. The list of successful candidates in 
the order of precedence is then published in the "Bulletin Officiel de 
la Marine," the last step "of this extraordinary examination, in which 
it is difficult to say which of the parties concerned seems to be the 
greatest object of suspicion, none being trusted to perform their 
duties from motives of conscience and honor. The government ap- 
parently takes the ground that "they may all be honest, but that 
they will all bear watching." 

It is certain, however, that no rejected candidate can complain of 
unfair dealing, as all are subjected to exactly the same ordeal by in- 
exorable machinery. 

As with us, the competition for the appointment of assistant sur- 
geon in the navy is open to any of the young men educated in other 
medical schools of the country, under certain conditions. The 
"facultes" of France confer separate diplomas for each branch of 
medicine, so that a student may have obtained a diploma for anat- 
omy or chemistry, but may not yet have been granted one for sur- 



NAVAL MEDICAL SCHOOLS OF FRANCE. 25 

gery or pathology, &c. To be admitted to the competitive examina- 
tions for appointment as assistant surgeons, it is required that the 
candidate, if not educated at a naval medical school, should have 
studied medicine two years and have eight diplomas. He must also 
be under twenty-three years of age. After three years of service, and 
six months at sea, assistant surgeons, having in the mean time taken 
their "doctorat," are eligible for promotion to the grade of "mede- 
cin " of the first class. 

The examinations to fill the vacancies in the medical corps of the 
navy are held every year, commencing on the 15th of September. 
They are announced two months in advance in the Moniteur. 



NAVAL MEDICAL SCHOOL, TOULON 



At Toulon, the old buildings continue to be used as a hospital and 
medical school. Founded many years ago for a different purpose, 
they are far from being well adapted to the one to which they have 
since been devoted, but have been modified to meet existing require- 
ments as well as circumstances would allow. A new edifice has been 
projected to replace the present one; but its construction has been 
delayed by the recent war, and the resulting change of government. 
It is designed on a magnificent scale; the estimated cost of its com- 
pletion being not less than five million francs. A copy of the plan is 
transmitted with this report. (Plate 2.) 

The rooms employed for instruction are for the most part in the 
basement of the hospital, and in other portions of the building, unsuit- 
able for the accommodation of the sick. There are three amphithe- 
aters, in which are delivered the lectures on anatomy, medicine and 
surgery, and chemistry. They are rather inconveniently small; but 
their limited size admits of the lectures being given in a comfortable 
and informal manner; the lecturer sitting, and addressing his discourse 
to the students in a semi-conversational tone, occasionally rising to 
illustrate his remarks with models or on the black-board. 

In the anatomical-lecture room physiology and anatomy are taught 
together by the same professor, who gives the function and uses of 
every tissue or organ in connection with its description. 

Adjoining the chemical-lecture room are the laboratory and depart- 
ment of pharmacy, both very completely equipped for the purpose of 
teaching, in a practical manner, chemistry and pharmacy, which are 
regarded as important branches of naval medicine. 

To avoid prolixity, I have omitted any account of the education of 
apothecaries, but will mention here that it is a feature of these schools 




var -inetfffy. 



Wuorc 




NAVAL MEDICAL SCHOOL, TOULON. 27 

that in them the apothecaries for the navy are educated by the s^ate, 
as well as the surgeons. These " pharmaciens," as they are called, 
form a regular corps in the French navy, of very respectable stand- 
ing, and are required to pass competitive examinations for appoint- 
ment and promotion. Those holding the position of "pharmacien- 
en-chef" have the assimilated rank of "capitaine de vaisseau," 
(colonel.) No student can be admitted to the school of pharmacy unless 
he has taken his degree as a bachelor of sciences. 

There are several commodious dissecting-rooms, in which there is 
never any lack of " material ; " the mortality of the hospital supplying 
an abundance of subjects. After the death of a patient, the remains 
are placed in the "chapelle blanche," or mortuary room, for twenty- 
four hours, and, if unclaimed at the end of that time, are transferred 
to the dissecting-rooms, on the same principle, I suppose, as the sug- 
gestion made by one of the professors here to take, in case of need, 
a piece of a pulpit for a splint, "La fin Justine les moyens!" On 
entering these rooms, I have always been struck with the admirable 
manner in which the subjects were preserved. Not only is there no 
unpleasant odor, but the color, humidity, and flexibility of the muscles 
and organs seemed to remain unimpaired for weeks. Remembering 
the difficulties encountered by the Examining Board in Washington 
in this respect, I made particular inquiry as to the method of preser- 
vation adopted, and have been informed that it is that proposed in 
1873 by Dr. Charles Leprieure of the military medical school of Val- 
de-Grece. Dr. Merlin, the professor of anatomy, was kind enough 
to explain to me the nature of the preservative fluid employed, and 
also to show me the process by which it is used. It is prepared ac- 
cording to the following formula: 

Phenic acid, 2 ~) 

Arsenious acid, 2 

Glycerine, 10 ]> parts in a hundred. 

Acetate of soda, 10 

Water, 763 



2S 

The injection is not made with a syringe, but by means of hydro- 
static pressure, with a simple apparatus arranged by placing a large 
glass jar containing the solution in the room above and connecting 
with it an India-rubber tube of suitable size, which is conducted 
through the floor to the subject below, and, by a slender nozzle, intro- 
duced into the carotid artery and secured. The pressure of the fluid 
is controlled by a stop-cock so as to maintain it moderately and con- 
tinuously until every part of the subject is saturated. The quantity 
required is generally from 5 to 7 liters, (7^ to 10^ pints.) In sub- 
jects thus preserved, the muscles remain rosy for two months, the skin 
retains its natural color, visceral cavities left open are unaffected by 
putrefaction, and even the brain keeps its consistency for 15 or 20 
days. Thinking this matter one of interest and value, I have sent to 
Paris, and procured the brochure of Dr. Leprieure on the subject, and 
transmit it with the other documents accompanying this report. 

The museum of this school, enriched by contributions from all parts 
of the globe, made during many years by scientific officers, affords 
unusual facilities for the study of ethnology, comparative anatomy, 
natural history, and the pathology of diseases of warm climates. 

It contains several interesting specimens said to be unique of their 
kind in the world. It is very much to be regretted that the space for 
storing this valuable collection is so inadequate. A ministerial regu- 
lation requires medical officers of the navy of France to procure 
objects of natural history, during their voyages, for the museums of 
the medical schools, and directs commanding officers to assist them 
in accomplishing this duty. 

The botanical garden belonging to the school, formerly in the city 
of Toulon, has been removed to Saint Mandrier, and will be described 
in the report on that institution. Each of the medical schools is 
obliged by regulation to maintain a garden of this kind. The library 
contains a large number of volumes, embracing all the classic and 
standard authors in medicine and the allied sciences, and a variety of 
medical periodicals. There are also many books of general interest, 



NAVAL MEDICAL SCHOOL, TOULON. 



20 



such as voyages and expeditions, subjects connected with a naval 
career. The library-rooms, three in number, are fitted up with long 
tables, and are used as a study by the pupils of the school, who thus 
find access to many sources of information which would otherwise be 
beyond their reach. In these rooms are also kept a number of micro- 
scopes, which are always at the disposal of the students, and a com- 
plete collection of surgical and obstetrical instruments for purposes 
of examination and reference. These cannot be removed from the 
room. 

The only expense incurred by students who have been admitted 
into the school is a trifling sum, paid annually, as a fee for the use of 
the library, which is employed to assist in replacing any books which 
may be injured. This fee, I think, is not more than fifteen francs, or 
about three dollars. 

The following is the curriculum of studies, and the list of the faculty, 
at the school of Toulon: 



Subject. 


Professor. 


Rank. 


Medical Jurisprudence •. .. 


Arlaud 

Barrallier 

Ollivier 

Cuneo 

Barthelemy . . . 

Beau 

Merlin 

Delmas 

Fontaine 

Delavaud 

Hereaud 

Michel 

Quetand 

Geoffroy 

Sambuc 


Directeur. 


Clinical Medicine ; Medical Pathology . . 
Materia Medica; Toxicology 


Medecin-en-chef. 
Medecin professeur. 
Medecin professeur. 
Medecin professeur. 
Medecin-en-chef. 


General and Naval Hygiene 


Clinical Surgery; Surgical Pathology... 
Operative Surgery . 


Anatomy and Physiology 


Medecin professeur. 
Medecin i re classe. 
Pharmacien-en-chef. 


Obstretrics and Diseases of Women 

Chemistrv and Toxicology 


Pharmacy ; Medical Physics 


Pharmacien-en-chef. 


Medical Natural History 


Pharmacien professeur. 


Descriptive Anatomy 


General Pathology .... . 


Me"decin i re classe. 


Minor Surgery and Bandaging. 


Medecin i re classe. 


Extemporaneous Pharmacy 









PERSONNEL. 

Dr. Arlaud, the director of the school of medicine and of the naval 
hospitals of Toulon and Saint Mandrier, is the third officer in seniority 
on the active-list of the medical corps of the navy. He is 58 years of 



30 

age, and has been in the service 38 years. His official title is " direc- 
teur du service de santi," (medical director,) and he has the assimi- 
lated rank of rear-admiral. In addition to his administrative func- 
tions, he also delivers the lectures on legal medicine. He enjoys a 
high reputation as a surgeon, and has amassed a large fortune by his 
operations and private practice. In conjunction with his colleague. 
Dr. Roux, who is now the " medical inspector-general," he performed, 
at the hospital of Saint Mandrier the operation of amputation of the 
hip-joint four times with four recoveries, a success more remarkable 
than any that has ever before come to my knowledge, though it is to 
be noted that none of the cases were " primary " operations, but were, 
all " secondary," or rather were all performed for the relief of chronic 
affections.) The account of these cases has been published by Dr. 
Roux in the " Gazette Medicale Hebdomadaire." Having seen Dr. 
Arlaud operate several times, I can testify to his dexterity, as well as 
to his extreme ingenuity in the way of contrivances to meet exigen- 
cies. One of the latter, a device for the extemporaneous treatment 
of fractures on the road or in the field, seemed to me so useful that 
I have obtained a description of it, and transmit it with this report. 

Dr. Barrallier, who is the professor of clinical medicine and medi- 
cal pathology, is the senior " medecin-en-chef " in the navy, and, by 
the retirement of Dr. Rochard, will shortly be promoted to the posi- 
tion of director of the naval medical school at Brest. He is 61 years 
of age, and has been in the service 41 years. Notwithstanding that he- 
is somewhat advanced in age, he is an industrious and devoted laborer 
in his profession, and one of the most instructive lecturers, both clini- 
cal and ex cathedra, that I have ever heard. He is a constant con- 
tributor to the medical literature of France. 

Dr. Barthelemy, lecturer on surgery, has been in the service 26 
years, and has the rank of " midecin professeur." He is also an ad- 
mirable teacher and a skillful operator. I had the opportunity of see- 
ing an amputation of the thigh performed by him in a case of a most 
interesting character, as it was a wound of the knee from the ball of a 



NAVAL MEDICAL SCHOOL, TOULON. 31 

chassepot rifle. The projectile had entered the joint, and there ex- 
ploded, producing an injury of as terrible a nature as can well be con- 
ceived. " Comminution " will not express the resulting condition of 
the ends of the bones : they were powdered — reduced to a mass of 
fine osseous particles, as if they had been ground in a mill, and both 
femur and tibia fractured, besides, at a distance of some inches from 
the joint, by the shock of the explosion. I am the more impressed 
with the destructive power of this weapon from having seen a photo- 
graph of a soldier who had been struck by a chassepot bullet, which 
entered under the chin and passed obliquely upward and backward. 
The skull was entirely emptied of its contents, and nothing of the 
face remained but the mouth. 

Dr. Beau, teacher of operative surgery, has been in the service 39 
years, and is the second in seniority of the " medecins-en-chef." He 
has published some valuable suggestions in regard to the treatment 
of fractures, in a small volume, which I herewith transmit, accompa- 
nied by photographs of the apparatus he has invented. 

Dr. Merlin, lecturer on anatomy and physiology, has been in the 
service 25 years, and has the rank of " medecin professeur." He has 
written a very interesting review of the medical and surgical history 
of the war in America, a copy of which accompanies the other doc- 
uments herewith sent to the bureau. 

Dr. Fontaine, professor of chemistry and physics, is second in 
seniority of the "pharmaciens-en-chef " of the navy. He is 56 years 
of age, has been in the service 39 years, and has the assimilated rank 
of " capitaine de vaisseau," (colonel.) He occupies a very high posi- 
tion, both socially and professionally, and is much respected and es- 
teemed by his colleagues. It is freely admitted that there is no mem- 
ber of the faculty of this school superior to Dr. Fontaine in ability 
and learning, and in all the qualities that make the gentleman and 
the scholar. Surely there is no greater contrast than that between 
the position of a pharmacien in the French navy and that of an 
apothecary in the navy of the United States, unless it may be between 
the different manners in which their respective duties are performed. 



32 NAVAL MEDICAL SCHOOL, TOULON. 

Any discussion of the vexed question about the position of the 
apothecaries in our service would be out of place here; but perhaps 
the question may be pertinent as to whether there is not a lesson for 
us to be learned from the experience and usage of other nations in 
this respect. 

Without extending in further detail this mention of the medical 
officers who act as teachers in the school of Toulon, I will add that, 
from the ample opportunity I have had of forming an opinion, I 
believe I am justified in saying that, in learning and acquirements, 
they compare favorably with the faculties of many medical colleges 
in the United States. That their instruction is thorough is proven by 
the fact that their pupils pass successful examinations before the 
faculties of Paris and Montpelier, where the requirements are well 
known to be rigid and impartial; 

The method of teaching is rather different from ours, but resembles 
that in vogue in the hospital-schools of Paris. A clinic, medical and 
surgical, on the alternate days, is held in the wards of the hospital 
every morning at the early hour of 8 o'clock,. before breakfast. Dur- 
ing the hour from 8 to 9 a. m., the professor, attended by his class, 
passes through the wards, examines the patients, diagnoses the cases, 
prescribes for them, explains them in a familiar and pleasant way, 
and questions the students on practical points, taking notes of their 
aptitude and intelligence. These notes are referred to at the time of 
the examinations for appointment. After the clinical hour, a lecture 
is delivered in the amphitheater, from 9 to 10; generally a written 
discourse, which forms part of a regular series. Attendance on the 
clinics and on the lectures is obligatory, and all absentees are noted 
by the prevot. After an hour's interval for breakfast, another lecture 
is delivered at 11 o'clock, and again at 3 o'clock in the afternoon; 
the intervening time being occupied by the labors of the dissecting- 
rooms and laboratory, or in reading in the library. 

A weekly bulletin stating the hours for the lectures and the sub- 
jects is posted at the entrance to the hospital. 



NAVAL MEDICAL SCHOOL, TOULON. 



33 



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34 

The appearance of the young men who are enrolled as students in 
this school indicates that they are of more than average intelligence 
and culture. There are about 120 in all, of whom 75 are in the sec- 
ond or junior class, and 45 in the first or senior class. The latter 
will compete for the appointment of assistant surgeon in August next. 
Out of the 40 or 50 examined every year in Toulon, a proportion of 
about 10 come up to the standard of requirement. The unsuccess- 
ful are allowed to remain another year under instructions, and to pre- 
sent themselves a second time for examination ; but a second failure 
excludes them from the school and from the service. 

The annual examinations held at the three naval medical schools 
of Toulon, Brest, and Rochefort supply an average number of about 
thirty assistant surgeons, to fill the vacancies in the medical corps of 
the navy. Of those who enter the schools only about one-half are 
found to be remaining at the end of two years, when the time for ex- 
amination has arrived. Of these, about one-fourth succeeds in the 
competition for appointment, so that it may be said, speaking in gen- 
eral terms, that only. one-eighth of the students of these schools ac- 
tually enter the service and become assistant surgeons. Promotion 
thereafter must be likewise won by passing an examination for each 
of the following grades, which comprise the organization of the med- 
ical corps of the French navy : 

1. Inspecteur general. 

2. Directeur du service de sante. 

3. Inspecteur adjoint. 

4. Medecin-en-chef. 

5. Medecin professeur. 

6. Medecin principal. 

7. Medecin de premiere classe. 

8. Medecin de seconde classe. 



1i 




J7ujzI MediccU jSc7mol of Jvvojvcgs. 




OBSERVATIONS 



ON THE 



NAVAL HOSPITALS OF TOULON, FRANCE. 



PZATU.TK. 




NAVAL HOSPITAL, TOULON. 



This ancient structure, like so many of the hospitals of Italy and 
France, was originally a religious establishment, having been founded 
by the Jesuits, in 1686, as a seminary for the almoners (priests or 
chaplains) destined for service in the navy, but has been used for its 
present purpose for more than ninety years. (Plates 3 and 4.) 

Its locality, whatever it may have been at first, is objectionable at 
this time, being in the midst of the city, surrounded on three sides by 
narrow streets with high houses, and having on the fourth side an 
inclosure of limited dimensions. 

The architecture is massive and plain, excepting the entrance, which 
is elaborately adorned with Ionic pillars, in pairs, supporting an entab- 
lature which is surmounted by two colossal figures representing Pity 
and Fortitude, holding between them a shield bearing the arms of 
France. Above these there is a sort of belvedere, which is used as an 
observatory. This central building is five stories in height, the wings 
being of three stories, or rather of two and a basement. As will be 
seen from the accompanying plans, it is built around two quadrangles, 
of unequal size, and a third inclosure of a trapezoidal form, the prin- 
cipal court being in the rear, and in a great measure occupied by the 
outbuildings and appendages. The exposure of the building itself is 
good, as it faces full to the south; but the interior is so injudiciously 
divided that the reverse is true of the wards, three of the principal 
ones on each story facing east and west, in closed courts, and two 
other large ones on each story looking north on one side and into a 
closed court on the other. The result of this arrangement is that but 
little direct sunlight ever finds its way into the rooms where the sick 



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JPfcuz of Jico&e/ite/rct- 



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38 NAVAL HOSPITAL, TOULON. 

are congregated. Only the chambers for the invalid officers and two 
small wards receive the southern sun. The advantage of additional 
coolness in summer cannot compensate for the loss, during the whole 
year, of the hygienic and remedial influence of sunlight. The ca- 
pacity of the hospital is about three hundred beds, distributed in 
twelve wards and several private rooms. 

The dimensions of the wards, 100 by 30 by 15, are sufficiently good, 
and approach the accepted standard; the number of beds in each 
ward is not in excess, seldom more than 24. The cubic air-space 
per man is greater than in most hospitals in Europe — 1,875 cubic 
feet ; but all of these good points are at once neutralized by the fatal 
fault of having the wards communicating by open arches, which has 
the effect of converting them virtually into one immense ward, in 
which a large number of sick breathe a common atmosphere, and are 
consequently subjected to all the evils of aggregation, {e. g., wards 
7 = 8= 15, and 9 = 17 = 31 in the plan.) (See plate 4, ante.) 

The floors of the wards are of glazed red tiles, of hexagonal shape, 
fitted closely together with cement, and form an almost completely 
non-absorbent surface. The walls are covered with lime-wash, which 
is renewed twice a year. 

The ventilation is deficient; for, although each ward is provided 
with an abundance of opposite windows, six on each side, there is no 
movement of air in the narrow streets and closed courts On which 
they look, and the windows are not arranged so as to be kept suffi- 
ciently open. There is no artificial ventilation. 

The heating of the wards is effected by stoves which burn wood, 
and furnish an agreeable, but irregular, temperature. 

The beds are placed in opposite rows, two to each window, and 
are very comfortable and cleanly. The bedsteads are of wrought 
iron, with the open iron Rheocline springs, " like snakes sitting on 
their bottom coils," which allow the air to pass freely and directly 
under the mattresses. There are two of the latter to each bed, one 
stuffed with wool and one with hair, the woolen one being next to 



TOULON. 39 

the patient. They are frequently inspected, taken to pieces, cleaned, 
and made up anew, in a special room devoted to this purpose. 

The latrines are adjacent to the wards, and separated from them by 
a narrow passage. They are automatic, and well arranged for clean- 
liness, but not for comfort or convenience. They are excellently ven- 
tilated by pipes leading up above the roof, and kept disinfected with 
chloride of lime. The drainage of this hospital is like that of all the 
buildings in Toulon; the refuse being conducted into open gutters in 
the streets, along which rills from a mountain-stream are made to 
flow rapidly, and empty into the sea. 

Besides the wards, there are several very pleasant, cheerful, and 
sunny rooms for sick officers. They are warmed with open fire- 
places, and furnished with every comfort. 

The kitchen is spacious, well equipped, and provided with a large 
cooking-apparatus in the center of the room, thus securing a double 
amount of fire-space. It has communicating with it in a very con- 
venient manner the butchery and store-rooms, and, all of these being 
under the exclusive control of the sisters of a religious order, it is 
needless to say they are in admirable condition." Instead of being 
isolated, however, it is placed in the basement of the main building, 
and directly under one of the largest wards, a plan attended with 
many disadvantages. 

The laundry is at some distance from the hospital, and, in common 
with many others, is located on the banks of a small stream which 
descends from the mountains that environ Toulon, and flows through 
the city. I have not seen it, but am told it is like that of the civil 
hospital which I have visited, and with which I was greatly pleased. 
The water of the little river is allowed to run into and through sev- 
eral large tanks of cemented masonry, the curbs of which are of a 
convenient height for the operations of the washerwomen. Here the 
clothes are very readily washed and rinsed after having been boiled 
in copper caldrons near the tanks. They are then dried in the open 
air. This primitive but thorough establishment is also under the 



40 NAVAL HOSPITAL, TOULON. 

management of the sisters, by whom the linen is afterward arranged 
with great care and taste in the linen-room of the hospital in open 
racks instead of closets. 

The baths of the hospital are the most complete I have ever seen. 
They are in the basement, which appears an inconvenient disposition, 
as they are necessarily distant from the wards above. They embrace 
every variety of baths, cold, warm, douche, vapor, sulphur, and medi- 
cated, and are extensively used in the treatment of many disorders. 
Those intended for the use of officers are private, and fitted up in 
a superior manner. This department is the most advanced in the 
institution. 

ORGANIZATION. 

As the system of organization here is essentially different from 
ours, and as it is similar to that sanctioned by the usage of most of 
the continental hospitals of Europe, its consideration may be more 
instructive than the description of an obsolete edifice. The admin- 
istration of the hospital is conducted by three different authorities,, 
which are in a measure independent of each other, and the occa- 
sional jealousies between which are said to exercise a salutary influ- 
ence on the interests of the sick : 

i. The medical director, who has- control over the medical staff 
and over all matters relating to the reception and treatment of the 
sick; 

2. The commissary, who purchases all supplies, keeps an account 
of all the expenditures, and attends to the disbursements and finan- 
cial transactions involved in the business of the establishment ; 

3. The sisters of the religious order which is charged with the 
duties of nursing, cooking, washing, and the general mmage, and 
with the care of the hospital property, (internal.) 

While this arrangement curtails the authority, and, it may be, the 
importance of the medical officers, it has the advantage of freeing 
them from distractions and responsibilities in regard to things alien 
to their profession, while they have at the same time the assurance 



TOULON. 41 

that all the accessory duties are being well done by trained and com- 
petent persons. 

The commissary, knowing the disinterested scrutiny to which his 
purchases will be subjected, is naturally more particular in their 
selection. 

• The sisters, who perform their offices as a religious duty and in 
conformity to a vow, and who do not and cannot receive any com- 
pensation for their services, are less apt to neglect the sick intrusted 
to their care than hired nurses, who obviously must belong to a class 
inferior in intelligence and morals. 

These estimable women, who are thoroughly instructed in the art 
of nursing, have the superintendence of the wards; all the attendants 
being subject to their orders. They go about from bed to bed, hear 
the complaints and wants of the sick, and give them such help as 
they require. They also have the surveillance of the cellars and 
store-rooms, see to the preservation of the food, and that it is admin- 
istered to the patients without alteration in quantity or quality, and 
report any deterioration to the commissary. They keep an account 
of expenditures, and dispose of such viands as may be remaining 
after the meals of the day; have charge of the, linen-room and all 
the internal property and furniture of the hospital. 

The police duties of the hospital are performed by the prevot, who 
is a surgeon of the second class, assisted by three " garde-medecins," 
who are assistant surgeons under his directions. One of the latter 
is always on duty in a room of central location, ready to attend to 
any summons. They also receive the patients for admission. Ma- 
rines are stationed as sentries and guards at the entrance and in the 
different courts. 

As this hospital is designed for clinical instruction, all its arrange- 
ments are provided for the " service enseignant " as distinguished from 
the "service hospitalier simple." Attached to. each clinic, both 
medical and surgical, is the following numerous and complete 
personnel : 



i. One " medecin-en-cheif," who gives the clinical instruction, and 
delivers a course of lectures on the practice of medicine and pathol- 
ogy. 

2. One surgeon of the first class, chief of clinic, who prepares the 
clinics for his superior, and replaces him in case of absence. 

3. One surgeon of the second class, prevot, and aid to the clinic, 
charged with the discipline of the assistant surgeons and students. 
He calls the roll and notes absentees, attendance on the clinics being 
obligatory. 

4. From four to five assistant surgeons, who write the observations 
on the sick, and the remarks on diseases, in the clinical note-books. 

5. From ten to fifteen students, who have charge of the dressings, 
and who write the memoranda of diet and medicines, and make 
copies for the apothecaries and for use in the kitchen. 

Besides the above, there are in each ward : 

6. One sister, w T ho distributes the articles of food and diet, and ad- 
ministers the medicines which are to be given at particular hours, or 
for feeble patients. She also has the care of all the property in the 
wards, and the superintendence of the nurses, who are under her direc- 
tions. 

7. One apothecary of the second class, who prepares the prescrip- 
tions and attends to the extemporaneous pharmacy. He is assisted 
by a student of pharmacy. 

8. One principal nurse, male, who administers baths, enemata, and 
performs offices unsuitable for a female. He has also the surveil- 
lance of the patients. 

9. Two ordinary nurses, also males, who wait on the sick, make 
the beds, change the garments, &c. 

There are three classes of persons entitled to treatment in this hos- 
pital: sailors from the ships and land-establishments of the navy, 
workmen in the arsenal, and soldiers from the garrison ; the latter in 
consequence of the military hospital in Toulon being at present 
closed. 



NAVAL HOSPITAL, TOULON. 43 

As with us, each patient receives a tepid bath before admission into 
the ward. He is then provided with a cotton or woolen cap, a 
shirt, a cravat, a loose capote of gray wool, pantaloons, drawers, and 
a pair of slippers, conducted to a bed duly numbered, and his name, 
disease, and antecedents entered on a " tableau de clinique," marked 
with a similar number, and on which the memoranda of his case are 
kept as long as he remains under treatment. These "tableaux de 
clinique" are, I think, more complete than our case-papers, to which 
they correspond. They embrace all the particulars of diet and med- 
ication, and have attached to them the tables of temperature and 
sphygmographic tracings. When completed, they are filed and placed 
in the archives of the hospital. As it is sometimes a matter of inter- 
est to compare the methods in which different persons do the same 
thing, I transmit one of these papers, accompanied by some notes of 
treatment of ordinary cases, one of pneumonia and one of typhoid 
fever. 

The dispute existing in the United States and in England as to the 
relative advantages of treating pneumonia with or without blood-let- 
ting seems not to have extended to the south of France. Here, as 
of old with us, there is but one opinion, and bleeding is practiced in 
every case, both by venesection and by local depletion, and I must 
say, in most cases I have seen, with marked benefit. As a rule, the 
appearance of crepitation with a high temperature is the signal to 
take from the arm from one-half a pound to a pound of blood, and to 
cover the affected side with leeches; antimony being at the same time 
freely administered. A speedy fall of the temperature and resolution 
has generally been the result in cases thus treated under my obser- 
vation here. In this connection, I will mention that the stethoscope 
used in this hospital is of the solid variety, and of a model contrived 
by Dr. Barrallier, professor of pathology and practice. Its peculiarity 
consists in its aural extremity being expanded into a flattened disk of 
about three inches in diameter. It is a rough-looking instrument, of 
light wood, but assists the ear better than any I have ever tried, con- 



44 

verting a muffled, whispering murmur into a clearly audible bruit. 
A specimen of it is herewith transmitted. 

The management of typhoid fever here is extremely simple, and, I 
will also add, extremely unsuccessful. It may be, however, that the 
enteric fever at present endemic in the south of Europe is more than 
usually malignant and unmanageable. I am inclined to think that 
this is the case, as it appeared on board the Congress in a form that 
was absolutely "foudroyant." The adopted treatment at the hospi- 
tal in Toulon is by enemata of cold water, cool lotions to the surface^ 
a poultice over the abdomen, and the administration of quinine in 
tonic ( i -grain) doses. (See report of case appended.) Stimulants 
and concentrated nourishment, as far as I can learn, are not 
employed, as especially required in the disease, though the alimen- 
tation of all the sick comprises more or less of the light Provensal 
wines, or those of Bordeaux. The poultice used is a great improve- 
ment over that made of linseed-meal or even of spongio-piline. It 
is composed of compressed cotton, mingled with some sort of fucoid 
plant, also dried and compressed. When placed in warm water, it 
swells rapidly, and retains most admirably both the heat and moisture. 
A small portion of this fabric is inclosed as a specimen. 

The food supplied to the patients appears to be of excellent quality; 
and, its preparation being intrusted to the sisters, it is always well 
cooked. Bread, wine, soup or bouillon, fresh meat, poultry, and vege- 
tables are the principal articles, and the scale of diet is arranged by a 
reduction in the quantity of each article, so as to form a three-quarter,, 
a half, and a quarter diet. The light or fever diet consists of rice, tapi- 
oca, jelly, prunes, chocolate, and milk. Coffee is only given as medi- 
cine and tea is ignored. Much stress is laid on the appropriate use 
of the wines which enter into the allowance. They are carefully 
selected, and sent on a voyage before they are accepted at the hos- 
pital. The patients suffering from slight affections are given ordinary 
wine; but to those who are more seriously ill old and superior wines 
are administered. The convalescents receive a third and inferior kind. 

It cannot but be regretted that an organization so admirable should 



NAVAL HOSPITAL. TOULON. 45 

be compelled to exercise its functions in a building so imperfectly- 
adapted to the treatment of the sick. Their skill and devotion must 
often contend in vain against the evil influences which oppose them. 
I know not what the rate of mortality is; but I am satisfied, from my 
own observation, that it is fearfully great. One incident which has 
occurred during my visit here will suffice to show the condition ot 
things which prevails within its contaminated walls. A conscript, 
who had cut off the index-finger of the right hand to avoid service in 
the army, was brought to the hospital in a state of health perfect 
saving his insignificant injury. He was placed in the surgical ward, 
and within a week died with symptoms of typhoid poisoning. For 
nearly a hundred years, this edifice has had crowded into its unventi- 
lated wards numbers of diseased inmates until its very masonry is 
reeking with infection. 

The ground has been chosen, and the plans prepared, for a new 
naval hospital to adjoin the arsenal; and, as soon as it can be com- 
pleted, the one at present in use will be at once abandoned. 

As the designs for this contemplated hospital have been made by 
Mr. Janvier, a distinguished architect of France, recently deceased, 
and may be supposed to represent the advanced ideas of what a 
naval hospital should be, I have endeavored to procure a copy to 
send to the bureau. By the kindness of Monsieur Raoulx, engineer- 
in-chief of the arsenals, who has charge of the construction of all 
the hospitals and barracks for the navy, I have been furnished with 
a small sketch of the ground-plan; and Dr. Fontaine, pharmacien-en- 
chef, at the school, has undertaken to photograph the other drawings 
for my use. The wards seem to be arranged on the same principle 
as those of the Vincennes military hospital, in double pavilions, 
placed opposite to each other; the intervening space at the ends being 
only partly occupied by accessory buildings, so as to avoid the stag- 
nation of air in the angles. This hospital will be double the size of 
the one at Vincennes, and will contain nearly 1,200 beds, with about 
2,600 cubic feet of air-space per man. The plan is attached to this* 
report. 



46 



TYP.HOID FEVER OF GRAVE FORM TREATED WITH 
ENEMATA OF COLD WATER AND EXTERNAL BATH- 
ING WITH OXYCRATE, (DILUTED VINEGAR.) 

Lalondigue, Jean, a sailor on board of the Soiguelay, aged 22 
years, entered the naval hospital, Toulon, during the term of service 
of the " mtdecin-en-chef," on the 24th of October, 1874. 

24//Z October. — Has been sick for three days, and complains of pain 
in every part of the body, and especially in the lumbar region. 
Heat of the skin is intense. The thermometer placed in the axilla 
indicates a temperature of 41 Cent. The pulse is full and frequent, 
92 per minute. The face is flushed, the mouth dry and pasty, and 
there is great thirst. The patient coughs a little, and expectorates 
some mucous secretion. Respiration is freely performed. Exami- 
nation of the chest reveals a little dullness on the left side on per- 
cussion, and on auscultation some sonorous rales and a diminution 
of the vesicular murmur in the left lung, with some aegophony on the 
same side; nothing abnormal on the right side. There have been no 
evacuations of the bowels for two days. The abdomen is neither 
tender nor painful. 

An emetic was administered in the beginning of the treatment. 

25/^ October. — The night succeeding the entrance of the patient 
was uncomfortable, no sleep, and a good deal of disturbance toward 
morning; frequent evacuations of the stomach and bowels; abdomen 
painful upon pressure. Some gurgling could be heard* in the right 
iliac fossa, and rose-colored spots appeared on the abdomen. The 
pulse was dicrotic, 96 pulsations per minute. The tongue was foul, 
the mouth very dry, the pupils dilated. On the left side of the chest 
were some sibilant rales. Cough. Axillary temperature 40 C. 

Treatment was commenced at once, namely: a draught, with one 
grr.in of quinine, to be taken by spoonfuls every hour and at the 
same time an enema with 200 grammes of water, of the temperature of 
15OC. 



NAVAL HOSPITAL, TOULON. 47 

26th October. — Condition the same on the third day; the symptoms 
are rather aggravated. No sleep; a restless night. The patient*com- 
plains of severe general pain in all parts of the body. The tongue is 
dry and red on the borders and point; the teeth and lips are covered 
with sordes ; the abdomen is painful on pressure ; five or six stools in 
the twenty-four hours; the pulse is full and dicrotic, 92 per minute; 
temperature 40.7 C. 

Quinine again administered, and the temperature of the enema 
lowered to 8° C. 

2J//1 October. — Delirium declared itself on the fourth day. The 
face is red; the pupils dilated; the skin is warm and dry. The axil- 
lary temperature is 40. 7 ; the pulse is dicrotic, 88 per minute; the 
abdomen painful upon pressure, with numerous rose-colored lenticular 
spots. Six or seven liquid evacuations in the twenty-four hours. 

'Same prescription as in the night. / 

In the evening, the pulse is elevated to 96 per minute; temperature 
40.9 . Repeat the enema of water at 8° C. 

2gt/i October. — Eight days after the invasion of the disease, the 
temperature is maintained constantly at the same elevation, (4o°.7 C.;} 
the pulse at 96. The nights are restless; stools diarrhoeal. 

The temperature of the water given by enema is lowered to 5 C. 

29M October. — The symptoms still more aggravated; the skin is 
dry and very hot; the pulse small and very frequent, 112 per minute; 
the tongue is dry, with burning thirst ; the axillary temperature is 
raised still higher, 41.2 C. 

Two enemata of water at 5 C. prescribed, and at the same time 
general bathing with oxycrate every three hours. 

The temperature became lowered under the influence of the cold 
lotions, and the next day the pulse was only 104; temperature 40. °7 
C. The night was calm; no delirium; five or six diarrhoeal stools. 

Same prescription ; same lotions. 

1st November. — The heat of the skin is still less intense; the ther- 
mometer does not indicate more than 39-7° C; the pulse is 108. 



48 NAVAL HOSPITAL, TOULON. 

Two enemata were prescribed: one w r ith 200 grammes of red wine 
in the morning; the other in the evening with water at 5 C. Lotions 
every two hours, with a mixture of oxycrate and water, at 8° C. 

2d November. — On this day and for some days after the temperature 
oscillated between 39°.7 and 4o°.2 C, and the pulse between 100 
and 108. 

Same prescriptions. 

*]th November. — This morning the patient is more calm, and says 
he does not feel any pain. The pulse is 101, the temperature 39°.4 C. 
In the evening, there is extreme agitation; the skin is very hot; pulse 
1 to, temperature 42. 3 C. 

General bathing with oxycrate, and two enemata with water at 5 C. 

The next day, November 8, the pulse is still at 112, temperature 
40.7 C; but a remission occurred in the evening, the pulse became 
less frequent, and the temperature was 40.3 C 

gf/i November. — From the 9th to the 13th of November, very nearly 
the same temperature was maintained — 39-4° in the morning and 
40. 2 in the evening — while the pulse oscillated between 99 and 104. 
The same treatment has been continued until the present time, tlie 
twenty-third day after the invasion. 

13/^ November. — From the 13th of November, the temperature was 
not elevated above 39 C, the pulse becoming less frequent, and the 
patient more tranquil. The nights are quiet. 

The enemata of cold water are dispensed with from this time. 

i8//z November. — On the 18th, the patient complains of acute pain 
seated in the anterior and internal part of the right thigh, and on the 
posterior portion of the leg on the same side. There is no redness 
and but little swelling. 

This pain continued during several days, but yielded to some fric- 
tion with "huile de morelle," (nightshade.) 

Convalescence is established. The patient, who, up to this time, 
has taken only liquid aliment, is now placed on half-quarter diet. 



NAVAL HOSPITAL, TOULON. 49 

His appetite revives, his nights are good, and the diarrhoea dimin- 
ishes. 

29/A Nove??iber. — From the 29th of November up to the 2d of 
December, the patient was affected with profuse perspirations at night, 
which weakened him a little. 

$d December. — From this date, the patient got out of bed every 
day in the ward ; his strength returning little by little until his conva- 
lescence was fairly established. 

On the 21st of December, he was given his discharge, and presented 
to the council of health for the purpose of obtaining a sick-leave. 
4n 



NAVAL HOSPITAL OF SAINT MANDRIER. 



The magnificent harbor of Toulon is divided by projecting prom- 
ontories into two parts, the inner of which is known as the "lesser" 
and the outer as the "grand roads." On the southern shore of the 
latter, remote from the city and the arsenal, and the dense population 
which is crowded within their walls, is situated the famous hospital 
of Saint Mandrier. This noble structure, which is a monument of 
the wealth and power of France, as well as of the generous care she 
bestows on her sons when disabled in her cause, has been of im- 
mense service in giving succor to the sick and wounded on many 
occasions, both during the epidemics of cholera and plague by which 
Toulon has been frequently visited, and to the soldiers and seamen 
brought home from the wars in Algeria, the Crimea, and in Italy, 
and to those invalided from the colonies, especially from that most 
unhealthy region, Cochin China. 

The splendid and stately edifice, beautiful as it is with its roman- 
tic surroundings, is nevertheless, according to the views of modern 
science, but indifferently suited for a hospital. To the conveniences 
of accessibility and safety from foreign enemies have been sacrificed 
other considerations of the highest sanitary importance, causing de- 
fects now greatly lamented by the medical officers attached to the 
institution. Had it been placed on the opposite side of the penin- 
sula on which it stands, its situation would have been perfect in a sani- 
tary sense; but, as it is, not only does it face to the north, but close 
behind it rise hills of such elevation as to cut off from it the direct 
rays of the sun during the most of the day. It is thus deprived of 



NAVAL HOSPITAL OF SAINT MANDRIER. 51 

the great natural advantages which have made this favored Provencal 
region so sought after as a residence for invalids, viz : The protection 
from the cold northern winds given by the Maritime Alps, and the 
full exposure to the pure sea-breezes and warm southern air of the 
Mediterranean. In the case of the hospital of Saint Mandrier, these 
are precisely reversed. 

The building is composed of three isolated pavilions placed on the 
sides of a vast rectangular court, the fourth side of which is open 
toward the harbor and the opposite city. Each pavilion is three 
stories in height, three hundred and sixty feet in length, by about 
thirty feet in width, but the breadth is considerably increased by 
the addition of galleries which were built for the purpose of giving 
greater strength to the walls, and which now afford very convenient 
promenades under cover on all sides of the edifice. The floors are 
sustained by vaults or arches, and the whole building is of the most 
solid construction. 

Saint Mandrier was planned by an eminent architect named Rau- 
court, in the year 1817. The execution of the design required im- 
mense labor in leveling and terracing the hill-side on which it is built, 
and this labor, as is the case with all the great works about Toulon, 
was performed by convicts. It was occupied for the first time in 
1830. 

It was scarcely finished before it was proposed to change its desti- 
nation, some wishing to use it as an asylum — a sort of naval " Hotel 
des Invalides" — while others endeavored to have placed here the 
naval school of France. It was finally determined, however, to 
retain it for the purposes for which it was originally intended, that of 
a great receiving hospital. 

The total capacity of all the wards, including those in certain 
temporary buildings, is about 1,300 beds. 

The southern or central pavilion contains the administration, the 
pharmacy, the kitchen, the dead-house, the autopsic-room, cellars, 
store-rooms, &c; and on the upper floors, wards for sick officers and 



52 NAVAL HOSPITAL OF SAINT MANDRIER. 

the quarters of the medical staff. There is also a very handsome 
council chamber in it, intended for meetings of commissions and for 
consultations. The two other pavilions are devoted exclusively to 
the use of the sick, who occupy all three floors. Connection is estab- 
lished between the upper portions of the different pavilions by light 
wooden bridges. The wards are 120 feet in length by 27 in width 
and 14 in height, and contain each 36 beds, arranged in oppo- 
site rows, two beds between each two windows. The air-space 
per man is somewhat more than 1,260 cubic feet. 

The floors are of the same hexagonal red glazed tiles or bricks 
mentioned in connection with the Toulon hospital. These, being 
closely cemented together, form an excellent non-absorbent surface, 
easily cleaned, and agreeable to the eye. 

The walls are of plaster, and lime-washed. The ceilings constitute 
a serious defect, as they are composed of numerous narrow arches, 
instead of a plain surface; thus affording too many receptacles for 
impure air and exhalations. 

The ventilation is furnished entirely by the opposite windows and 
doors, assisted in winter by open fires; no artificial ventilation being 
employed. 

The wards are heated by open stoves, burning wood, and placed 
at about the junction of the central and extreme thirds of the apart- 
ment. 

The lighting would be ample, were it not that the external galleries 
make the rooms rather gloomy. It is obvious, from what has been 
said, that it is impossible for any rays of direct sunlight ever to reach 
any of the wards. 

There are no water-closets, but perambulating close-stools make a 
convenient substitute, which are either used out in the galleries or at 
once taken there from the bedside, and the contents removed to a 
distant point and there buried. The same disposition is made of the 
other refuse matters. 

The water-supply is derived from three enormous cisterns, with a 



NAVAL HOSPITAL OF SAINT MANDRIER. 53 

capacity of five millions of gallons. It is impossible to look at these 
colossal structures without admiration and astonishment. They are 
almost as extensive and as strongly built as those remaining on the 
site of ancient Carthage, and resemble the surviving works of a similar 
character left in many places throughout Southern Italy by the time- 
defying builders of Rome. Their reverberating echoes remind one 
of mighty caverns not made by the hands of man. 

Beside the three great pavilions which form the hospital proper, there 
is another spacious building, of nearly 800 feet in length, originally 
erected to lodge the host of convicts who toiled for thirteen long 
years in the construction of these massive edifices. It is now used 
as a venereal hospital and to lodge the workmen employed in the 
botanic garden, and also contains the laundry and other offices. 

The botanical garden formerly attached to the Toulon hospital 
has been removed to Saint Mandrier, and is a striking feature in 
the grounds which surround the institution. It is divided into six 
squares, four of which constitute the botanic garden in a strict 
sense, the fifth being a pleasure-ground, or " English garden," as they 
call it, and the sixth is a conservatory. The collection of plants is 
extensive and valuable, and is classified according to the system of 
Richardson. Here, as at Nice and Mentone, stately palm-trees grow 
in the open air, and it is a curious spectacle to see the great clusters 
of amber-colored dates ripening under a European sky. 

In the midst of the garden there is a most beautiful chapel which 
presents a really classic appearance. It is of a circular form, sur- 
mounted by a cupola which is supported by a double row of col- 
umns, the inner ones being of the Ionic order, and the outer elabo- 
rate Corinthian. This chapel is reached by a lofty flight of marble 
steps and the floor is of mosaic, made of the various marbles found 
in the vicinity. 

The organization of this hospital is so exactly like that of the sister 
institution previously described, that any account of it would be 
merely a repetition. The medical staff have charge of the treatment 



54 NAVAL HOSPITAL OF SAINT MANDRIER. 

and management of the sick, but have no further responsibilities con- 
nected with the establishment. The supplies are procured by the 
commissary, and the nursing and administering of medicine, as well 
as the cooking and washing, are exclusively in the hands of the sis- 
terhood of St. Vincent de Paul, one of the principal orders of the so- 
called sisters of mercy. 

I should be guilty of an unpardonable omission if in this connec- 
tion I failed to make acknowledgment of the kindness and courtesy 
shown me by the officers living at Saint Mandrier. On the occasion 
of my first visit to the hospital, in company with Medical Inspector 
Gihon, at that time fleet-surgeon of the European squadron, the 
Directeur du Sante and the other highest officials crossed the bay 
with us, and spent many hours in personally conducting us through- 
out the whole of the extensive establishment and explaining the ar- 
rangement of the different divisions. In all of my subsequent visits 
I was invariably received with the utmost amiability and politeness by 
the resident medical officers, who with unwearying patience submitted 
to all my questionings and seekings after information. I was partic- 
ularly struck with the intelligence and efficiency of the medical staff 
attached to Saint Mandrier, as well as with their absorbing devotion 
to their patients and their profession. I do not doubt that in courage 
and zeal they are the peers of those brave predecessors of theirs, 
nine of whom sacrificed their lives in succession in the wards of this 
hospital during an epidemic of cholera which scourged Toulon in 
x835. 



EDUCATION OF MEDICAL OFFICERS 



FOR THE 



PUBLIC SERVICE IN ENGLAND. 



Washington, D. C, March 21, 1876. 

Sir: Agreeably to your instructions of the 19th of June, 1874, I 
have the honor to transmit herewith a report of the special duty as- 
signed me in Europe. 

Having been informed that in the month of October, 1875, a class 
of candidates would be examined at the Army Medical School, Net- 
ley, for commission as assistant surgeons in the army and navy, I 
procured permission to proceed to England, with a view of being 
present at the examination, and making myself acquainted with its 
scope and character ; intending to visit, at the same time, the various 
military and naval hospitals of Great Britain. 

Regarding this as probably the most important part of my duty, 
on my arrival in London I presented to General Schenck, the min- 
ister of the United States, the letter of introduction with which I 
had been provided by the Department of State, with the request that 
he would obtain for me the sanction of the proper authorities to visit 
the institutions referred to in an official capacity. The desired per- 
mission was very kindly given in a note from the Foreign Office, of 
which the following is a copy : 

"The Earl of Derby presents his compliments to General Schenck, 
and, in reply to his note of the nth instant, has the honor to ac- 
quaint him that the necessary instructions have been given for afford- 
ing every facility to Dr. R. C. Dean to visit the military hospitals at 
Woolwich and Netley ; and that every facility will be afforded at the 
several naval hospitals to enable that officer to obtain such informa- 
tion as he may require, upon his official application. 

"Foreign Office, October 19, 1875." 

Feeling that I could now prosecute my investigations to acfvan- 



5S EDUCATION OF MEDICAL OFFICERS 

tage, I proceeded to Southampton, and found that my visit was ex- 
pected, and that all of the officers of the hospital as well as of the 
Army Medical School were prepared to aid me in every way. Pre- 
vious experience having taught me that but little knowledge of value 
is to be obtained by formal visits, and by merely walking through an 
institution and receiving explanations from officials, and that the best 
way of acquiring information of a useful sort is to become associated 
in some manner with the establishment to be examined, and to make 
regular and daily observations, I adopted the plan of going through 
the wards of the hospital every morning with the students and 
instructors, and afterward attending the lectures delivered by the pro- 
fessors to the candidates, and witnessing the analyses, autopsies, micro- 
scopic examinations, and other practical operations. The great 
courtesy and friendliness of the professors attached to the school 
enabled me to do this without embarrassment and in a way entirely 
agreeable to myself. Besides the information thus derived from my 
own observations, much supplementary knowledge was imparted to 
me by the various officials of the institution, who felt much interest 
in my mission. They all, indeed, seemed gratified by the fact that 
the Department desired information concerning the school, and very 
kindly referred to the circumstance in their lectures as an honor to 
them ; such allusions being also received by the candidates with 
demonstrations of applause. This feeling was no doubt in a great 
measure due to the fact, which I observed with much pleasure, that 
the medical authorities of the United States are held in high esteem 
here ; no other authors being more frequently cited, or spoken of with 
more respect in the course of these lectures. 

I do not doubt that I should have been able to' procure much in- 
formation that would have been of interest to the bureau in regard 
to this admirable school had it not unfortunately happened that, just 
as I was beginning to feel myself becoming acquainted somewhat with 
its organization and management, I was suddenly recalled to the 
Congress by a telegraphic order which compelled me to depart so 



FOR THE PUBLIC SERVICE IN ENGLAND. 59 

abruptly that I was obliged to leave much of my task unfinished. The 

imperfect character of the accompanying report must be attributed to 

the untimely interruption of my observations, which frustrated to a 

great extent the object of my mission. 

I need scarcely say that after having traveled so far, with this 

special object, and taken so much pains in advance, it was a profound 

disappointment to me, to be prevented from realizing the important 

results I had hoped for from my visit to England. 
Very respectfully, 

RICHARD C DEAN, 

Medical Inspector United States Navy. 
Surgeon- General J. Beale, U. S. N., 

Chief of the Bureau of Medicine and Surgery, 

Navy Department. 



EDUCATION OF MEDICAL OFFICERS FOR 
THE PUBLIC SERVICE IN ENGLAND. 



It cannot be otherwise than instructive to those who aim to im- 
prove the condition of the Navy, to examine and compare the sys- 
tems adopted by different nations for the education of the medical 
officers, to whom is intrusted one of the most important interests of 
the state, that of maintaining the health and consequent efficiency 
of its armies and fleets. 

In England, attention has been directed in a special manner of 
late years to this subject, and many wise reforms have been made, 
which have extended the duties of medical officers of the army and 
navy into new spheres of usefulness, ameliorated greatly the life of 
the soldier and the sailor, and secured for the government an increased 
amount of service from an unaugmented force. 

It is somewhat remarkable that in a country so conservative such 
radical changes should have been accomplished in so short a time, 
and a brief reference to the agencies by which they were effected will 
not be alien to the purposes of this report. 

That this was a question demanding the grave consideration of 
the government had been represented by many intelligent officers 
and writers whose views had weight in influencing opinion, and espe- 
cially by Robert Jackson, by Sir J. Ranald Martin, physician to the 
council of India, and by Dr. Parkes. 

In the concise language of the latter, it was declared that " the 
state employs a large number of men whom it places under its own 
social and sanitary conditions. It removes from them much of the 
self-control with regard to hygienic rules which other men possess, 
and is therefore bound, by every principle of honest and fair con- 



62 EDUCATION OF MEDICAL OFFICERS 

tract, to see that these men are in no way injured by its system. But 
more than this, it is as much bound by its own self-interest. It has 
been proved over and over again that nothing is so costly, in all 
ways, as disease, and nothing is so remunerative as the outlay which 
increases health, and, in so doing, increases the amount and value of 
the work done." 

At the same time that a better hygienic status of the army and 
navy was being advocated as a measure of expediency, the moral 
and humane aspect of the question was being most forcibly and 
successfully presented by arguments equally potent. 

Both public sentiment and parliamentary action seem to have been 
influenced in a great measure by the earnest exertion of two persons, 
whose names will be forever associated with the cause of humanity, 
Lord Sydney Herbert, Her Majesty's Secretary of State for War, and 
that noble woman of England whose life has been one long devotion 
to the relief of suffering. How well their labors are now appreciated 
by a grateful people may be seen in the splendid structure erected at 
Woolwich, the " Herbert Military Hospital," the most suitable memo- 
rial, and the most perfect institution of the kind in Europe, and by 
the fact that the name of Florence Nightingale is never mentioned 
without reverence throughout the length and breadth of the land. 

In consequence of the efforts referred to, a royal commission was 
appointed in 1857 to inquire into the sanitary condition of the army 
of England. "A new system of regulations was prepared by this com- 
mission, which entirely altered the position of the army medical officer. 
Previously, the army surgeon had been intrusted , officially merely 
with the care of the sick, though he had naturally been frequently 
consulted on the preservation of health and the prevention of disease. 
But the regulations of 1859 gave him an official position in this direc- 
tion, as he is ordered to advise commanding officers in all matters af- 
fecting the health of troops, whether as regards garrisons, stations, camps, 
and barracks, or diet, clothing, drill, duties, and exercises." 

"The commission also recommended that, to enable the armysur- 



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FOR THE PUBLIC SERVICE IN ENGLAND. 63 

geon to do this efficiently, an army medical school should be established, 
in which the specialties of military medicine and surgery, hygiene, 
and sanitary medicine might be taught to the young medical officers 
of the army." (Parkes.) 

The prosecution of these views led to the foundation of the now 
celebrated army medical school at the Royal Victoria Hospital at 
Netley. (See Plates VI, VII, VIII, and IX.) 

It is a significant fact that the establishmenr of this school was 
deemed by the commission the first step necessary to effect "an im- 
provement in the sanitary condition of the army," so that the institu- 
tion maybe said to have sprung from the requirements of an enlight- 
ened military administration, and to have been designed to assure to 
the state a class of medical officers of a high order of competency. 

But although it was on the recommendation of the royal commis- 
sioners that the army medical school was finally organized, the idea 
of such a school by no means originated with that body. It was Dp. 
John Bell, a distinguished surgeon and teacher of Edinburgh, one of 
a name and family that have given many honored members to the 
medical profession, who, seeing the low state of surgical knowledge 
among the naval surgeons of the fleet when he visited their hospitals 
at Yarmouth, after the battle of Camperdown, first called the attention 
of the British government to the necessity of establishing what he 
called a " great school of military surgery." The effect of this memoir 
was the establishment of the "military surgery chair" in the Univer- 
sity of Edinburgh. The first occupant of that chair was Dr. John 
Thomson, who was appointed in 1806, and was succeeded in 1822 by 
Sir George Ballingall, an army surgeon of experience, and author of 
the well-known " Outlines of Military Surgery." In the year 1805, Dr. 
Robert Jackson, often styled the " Prince of Army Surgeons," published 
his excellent treatise on the "Medical Department of Armies." In 
this work, Dr, Jackson unfolded^an elaborate scheme for "an army 
medical practical school," which he proposed to establish in con- 
nection with the invalid depot in the Isle of Wight. The plan of this 



Plate IX. 



L V! CTO^I A HOSPITAL 



SECOND FLOOR 




64 EDUCATION OF MEDICAL OFFICERS 

famous army surgeon was in all essential particulars the same as that 
laid down in the present constitution of the army medical school; 
this remarkable man having on this, as on so many other subjects, 
ideas in advance of the age in which he lived. The only step taken 
in this matter, until after the Crimean war, was the establishment of 
another chair of military surgery in Dublin. This and the corre- 
sponding chair in Edinburgh were finally abolished when the army 
medical school was organized in i860. 

The institution was first placed at Fort Pitt, Chatham ; but, in 1863, 
the Royal Victoria Hospital was opened at Netley, and to it were 
removed the school, the pathological museum, and the two libraries 
connected with the medical department of the army, as it was believed 
that young medical officers would have there better advantages for 
the study of disease. 

The results of the system were found to be so satisfactory that in 
1872 it was extended to the naval service; and candidates for the 
medical departments of the army, navy, and India services are now 
all required to receive here a supplementary education before being 
commissioned for actual duty. Officers of the royal engineers can 
attend the lectures on military hygiene, if they so desire ; and com- 
batant officers have the same privilege. All medical officers of the 
army and navy have access to the school. 

ORGANIZATION. 

Although located in the hospital, the medical school is not an 
appendage of it, but has a separate and independent existence under 
the Secretary of State for War. Its affairs are directed by a " senate," 
which is composed of— 

The medical director-general of the army, president ; 

The physician to the council of India ; 

The professors of the school ; 

The principal medical officer of the hospital. 

This body is invested with the power of regulating the amount and 



FOR THE PUBLIC SERVICE IN ENGLAND. 65 

character of the instruction, rules for the conduct of candidates, and 
methods of discipline, and controls the expenditures of the institution. 
Its acts require the approval of the Secretary of State for War. 

The object of the school being to give practical training in such 
branches only as will qualify the officer for his special sphere, the 
course is limited to the four subjects of — 

Military medicine ; 

Military surgery; 

Military hygiene; 

Pathology. 

Military medicine is taught clinically in the wards of the hospital. 
Special attention is given to investigating the history of the cases 
under observation, and to the forming of careful and accurate diagno- 
ses by means of the stethoscope, laryngoscope, ophthalmoscope, 
microscope, chemical tests, &c; and candidates are required to exam- 
ine men in the presence of the professors, to familiarize them with the 
processes of invaliding and recruiting. The management of hospi- 
tals, the art of nursing, diets in disease and convalescence, and the 
preparation of medical records and sick-certificates are all included 
in this part of the course. A series of lectures is also delivered by 
the professor of military medicine on the principal diseases to which 
soldiers and seamen are liable, and these lectures are made to embrace 
various collateral subjects, such as the history and literature of mili- 
tary medicine, the peculiar features of military and naval life with 
reference to morbific exposure, &c. Detailed accounts are given of 
tropical diseases, especially of yellow fever, malarious affections, dys- 
entery, and cholera, and of the different epidemics which may attack 
armies and fleets. Medical management by means of change of cli- 
mate, in convalescence from sickness, and in cases of health impaired 
in insalubrious countries, and the methods of making medical inspec- 
tions of troops and crews of ships to discover incipient or threatened 
disease, are explained at length. Lectures and clinical instruction 
are also given in mental diseases. 
5 N 



60 EDUCATION OF MEDICAL OFFICERS 

Military surgery is in like manner taught practically in the wards 
and by lectures. The latter are very comprehensive, and embrace, 
besides the usual subjects of surgical anatomy, inflammation, wounds, 
and operations, instruction in the various methods of transporting 
sick and wounded men, the fitting-up of transports and hospital-ships, 
use of ambulances, examination and classification of invalids, propor- 
tion of medical and surgical appliances to corps and divisions in 
different climates, surgical arrangements in landing on an enemy's 
coast, on taking the field, during and after an engagement, with an 
advancing army and with an army in retreat, with a besieging force, 
trench duties, and when within a besieged town or port. Dental and 
ophthalmic surgery are also included in this course, and the instruction 
in the use of the ophthalmoscope is given by the professor of military 
surgery. 

The lectures on pathology are delivered in connection with the study 
of the valuable specimens in the museum illustrating the morbid 
anatomy of the more important diseases incident to military and 
naval life ; and practical instruction is given in the making of autop- 
sies and necroscopic examinations, in the distinguishing of effects of 
disease from post-mortem changes, in the determining of the weight 
and bulk of organs, membranes, and fluids in health and disease, the 
normal and abnormal capacities of cavities. Practical instruction in 
the use of the microscope also pertains to this chair, as well as the 
art of drawing microscopic and other morbid specimens. 

But the most marked feature of this admirable school is undoubt- 
edly the department of hygiene, which stands unrivaled by any other 
similar institution in Europe or America. The instruction given here 
is of a character unique and precious, and is, in my opinion, the most 
advanced exponent of modern military medicine in its broadest and 
most comprehensive sense. So vast is the field and so manifold the 
subjects treated of in this division that it would almost seem as though 
it should be a school in itself. Rapid, concise, but systematic and 
thorough, teaching is given in the whole principles of hygiene and 



FOR THE PUBLIC SERVICE IN ENGLAND. 67 

their application to military life in every aspect and relation. The 
great work, of which the professor of military hygiene here is the 
author, is nominallythe text-book; but the range of instruction tran- 
scends that uf this invaluable volume, and reaches to most of the 
acquirements of finished medical scholarship. In addition to the 
daily practical exercises in the routine branches of hygiene, interest- 
ing information is imparted on such collateral or alliedsubjects as the 
comparative healthiness of different races, and their mental and physi- 
cal adaptability to military and naval service; influence of climate on 
health and life; acclimatization; geographical distribution of disease 
and mortality over the surface of the earth; influence of malaria; 
effects of emanations from animal matters on health; relations of dis- 
ease to overcrowded surfaces; defective drainage as predisposing to 
epidemics; the science of ventilation; accounts of arlimals from 
which food can be derived ; relative value of meats dried, smoked, 
salted, and fresh ; marks of disease in animals ; signs of wholesome 
and unwholesome meat ; the art of cooking ; nutritive value of vari- 
ous grains ; adulterations of flour ; examination of green vegetables 
used for food; the sources, collection, storing, and distributing of 
water; clothing; vital statistics; transmissibility of disease; influ- 
ence of light on health and disease; epidemic influences; plans of 
hospitals; burial of the dead; and many other subjects of the great- 
est practical importance. 

In consequence of the great amount of labor involved in the in- 
struction of this department, it is intrusted to two teachers, a pro- 
fessor and a conjoint professor of hygiene, who are aided by a third, 
with special reference to naval hygiene. 

FACULTY. 

The faculty of the school is composed of three medical officers of 
the army, one medical officer of the navy, two professors not con- 
nected with either branch of the service, and several assistants. As 
these gentlemen are well known to us by reputation, and by their ex- 



6S EDUCATION OF MEDICAL OFFICERS 

tensive contributions to medical literature, it was with much interest 
that I found myself brought into contact with them, and given the 
opportunity of making their personal acquaintance. 

Surgeon- General T. Longmore, C. B., the professor of military surgery, 
is an officer of prepossessing personal appearance and manners, an 
agreeable as well as an instructive lecturer, whose discourses bear 
evidence of the widest experience and research, and whose opinions 
are evidently the result of much philosophic thought. The numerous 
orders and medals worn by him attest the appreciation of his merits 
by his government. 

I was fortunate enough to be present during his lectures on the 
important subject of " Gun-shot Wounds of the Head." The views 
he expressed as to the treatment of such injuries were sustained by a 
remarkable array of facts drawn from a variety of sources. 

He deprecated the use of the trephine, or the probe, or any attempt 
to extract the projectile when lodged in the brain, and cited the ex- 
perience of the most eminent surgeons in the Peninsular, Crimean, 
Italian, and Franco-Prussian wars, who were unanimous in their 
opinion as to the evil results of such an interference. He stated, at 
the same time, most frankly that the numerous and valuable cases so 
ably reported by American surgeons during the war of the rebellion 
went far to establish the contrary, and that, out of respect to them, he 
would defer any positive statement of a precept until after the com- 
pletion of the publications from the office of the Surgeon-General of 
the Army of the United States. I have been impressed with the fact 
that, although Professor Longmore's ideas are quite at variance with 
the usual practice in this country, they have been curiously borne out 
by the reports of the first case of the kind which has been brought to 
my notice since my return. It is interesting to observe that the theory 
of defense in a recent trial of a well-known citizen of New Jersey 
should have affirmed the principle that the fatal injuries were more 
likely to have been caused by the frequent use of the surgeon's probe 
than by the bullet which had entered the brain of the deceased. 






FOR THE PUBLIC SERVICE IN ENGLAND. 69 

• 

This theory was entirely supported by the necroscopic appearances ; 
the ball having been found encysted in the brain only one and a half 
inches from the external wound, while probes and catheters had 
been three times passed a greater distance into the brain, once as far 
as two and a half inches. A corresponding number of abscesses were 
found in the posterior right lobe of the brain, which were believed to 
have been the immediate cause of death. 

In these lectures, Professor Longmore advocated the adoption of a 
common classification of gun-shot wounds, to be used by all nations, 
so as to avoid many difficulties which now exist in comparing the 
accounts of different authors. While he holds it to be unimportant 
whether the primary division be made into " regions," and the sec- 
ondary into the character and complications of the wounds, or the 
converse, he thinks it very desirable that the same classification 
should be used by all writers. He said he had found a ready assent 
to his proposition from European surgeons, but not from those of the 
United States, who preferred to retain their own system. 

Deputy Inspector- General W. C. Maclean, C. £., is an officer in the 
prime of life, and of a commanding stature and presence, with a coun- 
tenance strongly indicative of his Scottish origin. He is a native of 
Argyleshire, and a genuine type of the Highlander. He resides in 
Southampton, where he is a citizen held in high esteem. His lec- 
tures are forcible and eloquent, and enriched by the gathered inci- 
dents of a vast and varied experience, especially in India, and are 
delivered with the peculiar but impressive accent of that northern race, 
which has ever held a foremost place in the ranks of the medical pro- 
fession. 

A coincidence sufficiently remarkable to be noted occurred in con- 
nection with his course while I was present at Netley. In a discourse 
on diseases of the liver, he stated to the class that, according to his 
observations, abscesses of that organ were more frequently evacuated 
into the lung than externally or into the stomach or bowels. Almost 
at the moment of this statement being made, a patient in one of the 



70 EDUCATION OF MEDICAL OFFICERS 

wards died from the rupture of a hepatic abscess into the lung, and 
the autopsy, attended by the class after the lecture, furnished an 
illustration never to be forgotten. 

The most interesting lectures on military medicine delivered dur- 
ing my visit were those on yellow fever; and I was particularly 
pleased to hear from Dr. Maclean himself the admirable account of 
the two forms of the disease, long confounded, as I knew he had 
been, if not the first, among the earliest to point out the distinction 
between them. The clear differentiation given in Aitken's works 
between the true specific yellow fever and the resembling malarial 
fever was furnished by Dr. Maclean, and the tabulated differential 
diagnosis between the same two diseases published in the report of 
Deputy Inspector-General Donnet, of the royal navy, to the admi- 
ralty, though more concisely and conspicuously stated, and, doubt- 
less with equal originality, was subsequent to that of Dr. Maclean. 

In reply to some inquiries I made as to the success of the cin- 
chona forests planted on the Nilgherry Hills of India, I was in- 
formed by Dr. Maclean that they had prospered beyond expectation, 
and that the yield of yellow bark was now very abundant from them, 
and of a quality equally rich in quinia with that of the Loja region 
in South America. For the purpose of placing this useful remedy 
within the reach of the poorer classes, the plan has been adopted of 
treating the bark with muriatic acid and other solvents of the cin- 
chona alkaloids, and without going to the expense of separating the 
quinia, using the whole of the unpurified mixture of alkaloids with- 
out refining, which had been found a very efficient anti-periodic, and 
could be furnished in India at the cost of a shilling a pound ! 

Considerable use was also being made at Netley of the salicylic 
acid, made in Germany by synthesis at a very economical cost, as 
an anti-periodic remedy in intermittent fevers. The results were 
quite satisfactory. 

The proprietor of an empirical remedy, known as " Warburg's 
Tificture" came to Dr. Maclean just before my arrival, and made 



FOE THE PUBLIC SERVICE IN ENGLAND. 71 

known to him the composition of the medicine, and also prepared 
some in the laboratory of the hospital. As it had been found promptly 
efficacious by many of the English army surgeons in India and else- 
where as a remedy in malarious fevers when everything else had 
failed, much curiosity was felt to ascertain its ingredients. The fol- 
lowing is the formula as given me by Dr. Maclean : 

Aloes Socotrin. fbj. 

Rad. Rhei, 

Sem. Angelicse, 

Confection. Damocratis, ad 1 iv. 

Rad. Helenii (Enulas), 

Croci Sativi, 

Sem. Fceniculi, 

Cretse Preparatse, da 1 ij. 

Rad. Gentians, 

Rad. Zedoarise, 

Pip. Cubebse, 

Myrrh., 

Camphor., 

Bolet. Laricis, da ^j. 

Alcohol., gall. iv. 

Digest for twelve hours, strain, and add 
Quiniae Sulphat., 5 x - 

The " Confectio Damocratis" is a combination of thirty aromatic 
substances, formerly officinal in the London Pharmacopoeia, and still 
made by English druggists, and the "Boletus Laricis" is an active 
cathartic, not officinal. The dose is one-half ounce, to be repeated 
in three hours. It is probable that such a heterogeneous mixture as 
this will be regarded as a curiosity rather than anything else; but not- 
withstanding its singular and apparently absurd composition, I was 
assured by Dr. Maclean that it had invariably proved in his hands 
by far the most prompt and effective and reliable remedy in remittent 



72 EDUCATION OF MEDICAL OFFICERS 

and intermittent fevers he had ever known, and that the experience 
of many eminent army surgeons coincided with his own. It is 
referred to in " Reynold's System of Medicine," and its composition 
has since been published in one of the English medical journals with 
the warmest recommendations of several distinguished physicians and 
surgeons. It may be worth remembering in the treatment of those 
numerous cases of malarious fevers in which quinine alone proves 
insufficient. It has, at all events, the merit of being recommended by 
the highest authorities, after personal experience in its use, and has 
been well spoken of by Sir James Gibson, (medical director-general 
of the army,) Sir Andrew Halliday, Dr. Babington, and Mr. Skey. 

Both the military medical officers above mentioned, by virtue of 
their position as professors in the army medical school, enjoy an ad- 
vanced rank, and have been made " Companions of the Most Honor- 
able Order of the Bath." 

Dr. Aitken, whose invaluable work on the practice of medicine 
has given him such wide renown, is also one of the many distin- 
guished men whom Scotland has given to the medical profession. His 
lectures on pathology are replete with learning, and would do high 
honor even to the great school of Edinburgh, where, from his char- 
acteristic accent, one might fancy them to be delivered. 

In one of his discourses he spoke in complimentary terms of the 
practitioners of the United States, and made quotations from Drs. 
Hartshorne and Clymer, whom he referred to as high authorities. 

I had the privilege of spending a very profitable hour with him in 
the Pathological Museum, in conversation and in the examination 
of his most interesting specimens. He is a very modest and unas- 
suming man, and, from his retiring manners, I infer that, unlike his 
military colleagues, he has always led a life of seclusion and study. 
His instruction in the pathological room, where the microscopic ex- 
aminations of morbid tissues are made, are considered especially 
valuable, as there each individual student receives personal attention 
from him, and his vast information is imparted in an informal and 
colloquial fashion. 



FOR THE PUBLIC SERVICE IN ENGLAND. 73 

Dr. Parkes, the professor of hygiene at Netley, was convalescing 
from an attack of illness and from the effects of a fall during my 
visit ; but, notwithstanding that his disabilities obliged him to walk 
with two canes, he persisted in daily attendance at the school, and 
in superintending the arrangement of the tasks and practical work 
in his department, for the candidates. He has much quiet dignity, 
with a sweet and gentle face, which attracts everybody to him. His 
amiable character and conciliating manners have made him greatly 
beloved by the students, as well as by all who know him. He re- 
sides at " Bitterne," one of the pleasant little English villages on the 
line of the railway from Southampton to Netley, which has been 
constructed for the accommodation of the school and hospital. He 
is a member of the board of examiners in London for the examina- 
tion of candidates for admission into the army, and a Fellow of the 
Royal Society. As a medical man and a man of science he stands 
high in the estimation of the English people, and I have heard him 
spoken of with both admiration and affection by many army medical 
officers, in various parts of the world. * 

Surgeon- Major F. De Chaumont, R. A., is the conjoint professor of 
military hygiene, and gives lectures and practical instruction in the 
laboratory most useful in its character. 

Staff-Surgeon J-. Denis Macdonald, M. D., P. JV., a Fellow of the 
Royal Society, is assistant professor of hygiene, and instructor in all 
matters relating to naval hygiene and service afloat. 

Each professor has an assistant professor appointed to aid him in 
the work of instruction. These appointments are for five years, ex- 
cept in the case of Dr. De Chaumont, who, on account of his very 
special qualifications, has been appointed conjoint professor for per- 
manent duty. 

SYSTEM OF INSTRUCTION. 

Five days in the week are devoted to instruction; Saturday being 
a sort of " dies non," on which there are no lectures. Generally 

* Since the above was written this eminent man, to whom the world certainly 
owes much, has died, lamented by the entire nation. A message of kindest 
sympathy was sent him in his last hours by the Queen. 



74 EDUCATION OF MEDICAL OFFICERS 

not more than two lectures are delivered each day, the remainder 
of the time being occupied by clinical instruction in the wards, 
in the laboratory, in the microscope-room, museum, or libraries. 
Candidates are required to remain in the wards from 9 o'clock to 
11.30 a. m. Attendance on the lectures is also compulsory, and the 
class is expected to be assembled before the hour of lecture. No ex- 
cuse is received for non-attendance excepting duty elsewhere, or 
leave of absence granted by the proper authority. The penalty for 
being late at lectures is the loss of 10 marks, and that for absence 
the loss of 25 marks ; these numbers being deducted at the end of the 
term from the aggregate of marks by which relative position is as- 
signed. An examination is held at the end of the session on the sub- 
jects of the lectures, and the marks obtained are consulted in arrang- 
ing the places of the candidates on the list of assistant surgeons when 
commissioned for service in the army or navy. 

The manner of conducting the instruction in the laboratory is ex- 
tremely practical and thorough. On the two occasions on which I 
was present, the subjects under consideration were the testing of air 
for impurities and the examination of flour to discover adulterations. 
For the former purpose, the professor caused air to be collected in 
suitable vessels from three different localities external to the hospital, 
and also within the room where the students were gathered. He 
then described the processes of analysis intended to be used, giving 
formulae and illustrations on the blackboard, after which each candi- 
date was required to perform the analysis and write the result on a 
tablet. The calculations were then reviewed and compared, and 
errors corrected when existing. Every candidate is provided with a 
separate desk and shelf, furnished with the chemical reagents and 
apparatus necessary in such examinations, and does his work without 
consultation with his companions. Constant practice of this kind 
soon gives skill in manipulation, and I observed that the analyses 
seemed for the most part accurate, and received the commendations 
of the professor. In the second instance, after the various methods 



FOR THE PUBLIC SERVICE IN ENGLAND. 75 

of testing the quality and purity of flour had been recounted, each 
candidate was furnished with a sample of flour, and required to make 
the analysis and reduce the results to writing. 

In like manner, examinations are made of water, wines, beer, vine- 
gar, fabrics used in clothing, various soils, and everything pertaining 
to the sanitary science of military life. . ■ 

In this connection I will state that I have had numerous occasions 
to witness the truly valuable services which the medical officers edu- 
cated here have been enabled, by their special training, to render, 
not only to the garrisons and ships to which they were attached, but 
also to the whole community in which they lived, by the inspection 
of animals, the analysis of meat, determining the wholesomeness of 
air and water, &c. — duties of the greatest usefulness, which cannot, 
as a general rule, be performed in so practical a way by members 
of the medical profession. At Gibraltar and Malta especially, where 
large garrisons are stationed, these duties are regarded as of the high- 
est importance. 

In the pathological room, the practical instruction is managed in the 
same way. Every candidate is provided with a microscope, and is 
exercised in the examination of tissues and morbid products, as well as 
in the drawing and measuring and preserving microscopic objects. All 
;he class is required to be present at every post-mortem examination. 

MUSEUM. 

The museum is well suited for its purpose, and contains many 
interesting specimens of pathology, illustrating the diseases of tropi- 
cal climates, wounds from various projectiles, results of operations, 
&c. Perhaps the most valuable portions of it are the complete col- 
lection of parasites which produce disease, its ethnological specimens, 
and the models of hospitals and apparatus for the succor and trans- 
portation of wounded men. 

LIBRARIES. 

Two libraries furnish to the students the works of standard authors 
in medicine and science, and a pleasant and commodious reading- 



76 EDUCATION OF MEDICAL OFFICERS 

room gives every facility for the examination of prints and the con- 
sultation of maps and charts. 

During the period of his attendance at the school, every candidate 
has an allowance of five shillings a day, and is furnished with quarters 
in a handsome building erected for the purpose near the hospital. 
The mess-room and parlor are spacious and comfortable apartments, 
and all the arrangements, as in every English military mess, are com- 
plete and perfect. 

With kind and courteous hospitality, Colonel Gordon, the com- 
mandant of the post, and Surgeon- General Fraser, the principal 
medical officer of the hospital, invited me to become the guest of 
the mess during my stay, and to occupy rooms in the officers' quar- 
ters, besides showing me many friendly attentions, such as cultivated 
Englishmen know so well how to bestow in their homes. There 
were under instruction, at the time of my visit, about sixty students, 
most of whom were candidates for appointment in the army and 
navy, the remainder being intended for the India service, and some 
few being medical officers already in the service, but improving their 
knowledge of the specialties taught in such a thorough manner at 
this school. They seemed to be intelligent and cultivated young 
gentlemen, the material of which good officers are made. 

EXAMINATION OF CANDIDATES. 

The subject of the examination and qualifications of candidates 
for commission in the military and naval service of England is nat- 
urally connected with the consideration of the school where their 
professional training is completed. The system does not differ greatly 
from our own, but presents some features of special interest. Like 
our own, the examination is a competitive one. Every candidate 
desiring to present himself before the examining-board must be 
unmarried, and must be not under 21 or over 28 years of age. At- 
tested evidence of the date of birth must be furnished. Satisfactory 
certificates of moral character must also be produced. The candi- 



FOR THE PUBLIC SERVICE IN ENGLAND. 77 

date must himself certify that he is free from any mental or constitu- 
tional disease, and from any disability which could interfere with the 
performance of his duties as a medical officer under all circumstances. 
He must also pledge himself willing to engage in general service 
immediately. He must have a diploma in surgery, and a degree in 
medicine, or a license to practice it in Great Britain or Ireland. 

The examiners by whom the preliminary examinations are con- 
ducted are not, as with us, medical officers of the army or navy, but 
are four medical men connected with the University in London, who 
hold their sessions for this purpose at convenient times, generally 
between the courses, at Netley. 

The examination is upon the following subjects: 

Anatomy and physiology. 

Surgery. 

Practice of medicine. 

Therapeutics. 

Diseases of women and children. 

Chemistry. 

Pharmacy. 

Operations on the cadaver. 

Application of surgical apparatus. 

Clinical medicine. 

Comparative anatomy. 

Zoology. 

Botany. 

The three latter are not indispensable, but are considered in de- 
termining the relative position of successful candidates, a list of 
whom, arranged in the order of merit, is prepared by the board, and 
transmitted to the director-general of the army, and by him commu- 
nicated to the professors of the Army Medical School. 

The marks given to each candidate on each subject are attached 

to his name on this list, to be used in a manner hereafter described. 

It is not the practice in England to assemble an army medical 



78 EDUCATION OF MEDICAL OFFICERS 

board and a naval medical board ; but the preliminary examinations 
for both branches of the service are made by the same board. 

The four members who constitute this board, as at present organ- 
ized, are — 

Mr. Busk Anatomy and physiology. 

Mr. Pollock Surgery. 

*Dr. Parkes Medicine. 

Dr. Thomson Zoology. 

These gentlemen have no connection with the military or naval 
service. 

The plan of the examination resembles that in France, and differs 
from our own in the important respect that the same questions are 
submitted to all the candidates who are to compete with each other. 
I am indebted to Surgeon-Major Webb, R. A., assistant to the 
professor of military medicine at Netley, who kindly procured them 
at my request, for the examples of the preliminary examinations held 
in London in 1874 and 1875. 

jFrelimi'riary examination of candidates for Her Majesty's army, navy, 
and Indian services, London, August, 1874. 

ANATOMY AND PHYSIOLOGY. 

i. Classify the various kinds of articulation, and give an instance 
of each kind. Notice also those which illustrate the different forms 
©f lever. 

2. Give the origin, course, relations, and distribution of the glosso- 
pharyngeal nerve, and describe the dissection required to expose it 
in its course below the base of the skull. 

3. Enumerate the different kinds of glands that are found in the 
small and large intestines, and describe their minute structure and 
the physiological functions assigned to them. 

4. Give the dissection required to expose the supinator brevis 
muscle, and mention, in the order in which they appear, the parts 
that must be removed. 

* Since deceased. 



FOR THE PUBLIC SERVICE IN ENGLAND. 79 

5. How would you proceed to ascertain the presence of urea and 
sugar in the blood ? 

6. Describe the cochlea, its osseous structure, its membraneous 
portion, and the way in which the cochlear division of the auditory 
nerve is distributed. 

SURGERY. 

1. Describe the symptoms of concussion, the result of a fall or 
blow on the head. What subsequent symptoms might arise which 
would lead to an unfavorable prognosis, and upon what conditions 
would such symptoms depend ? State the treatment of a case of 
concussion. 

2. A man has general enlargement of the testicle. State the symp- 
toms which would indicate that it was a case of medullary cancer, 
strumous disease, or one of simple chronic inflammation. 

3. Describe the general and physical signs by which rupture of 
lung may be diagnosed in a case of fracture of the ribs, and the treat- 
ment to be pursued in such a case. 

4. Describe the symptoms of traumatic gangrene supervening on 
compound fracture of the leg.; and the treatment, both general and 
local. 

5. What are the earliest evidences of strumous disease of the hip- 
joint in a child ? What treatment, local and constitutional ? 

6. Mention the common forms of inguinal hernia in infants of both 
sexes. What treatment should be adopted in a case of undescended 
testicle in child the subject of inguinal hernia? 

medicine. 

1. What are the chief pathological changes in the serous mem- 
branes ? Give the symptoms of inflammation of the pericardium and 
of the peritoneum, and state what are the causes of these affections. 

2. State what is meant by the following terms, and what are the 
conditions in which the sounds referred to are heard:' venous hum; 
mitral obstructive murmur; aortic regurgitant murmur; pulmonary 
murmur; sound of a cracked pot; crepitation; metallic tinkling. 



80 EDUCATION OF MEDICAL OFFICERS 

3. Describe fully a case of chronic Bright's disease commencing 
insidiously and terminating by uraemia, and the probable causes and 
presumed pathological changes going on in the kidneys. 

4. Describe the following cutaneous eruptions : Sudamina, herpes 
zoster, urticaria, rupia, psoriasis, guttata, pityriasis. 

5. What are the principal astringents ? Give the chief pharmaco- 
pceial forms and doses of each drug you name, and state in what dis- 
eases it is principally employed. 

6. What are the chief causes of menorrhagia and dysmenorrhoea ? 
Give the treatment in each case. 

ZOOLOGY. 

1. To what order of mammals does the genus Felis belong ? Give 
its characters, enumerate its principal species, and state their geo- 
graphical distribution. 

2. State in general terms the structure of the eye in the different 
classes of the animal kingdom. 

3. Describe the nature and mode of growth of the horn in the 
order " Ruminantse." 

4. To what class of animals does the genus Helix belong ? Give 
its most important characters, and describe its respiratory and gener- 
ative organs. 

5. Describe the wings of birds, bats, and flying squirrels, pointing 
out the homologies of their parts. 

6. What use do birds make of the force of gravity in propelling 
themselves through the air, and by what means is the movement of 
" soaring" accomplished? Describe the wing of the eagle with ref- 
erence to the mechanical powers employed in its action. 

BOTANY. 

1. Explain the terms epiphite and parasite, and give an account of 
the different kinds of parasites in plants. 

2. Give the characters of the natural order of " Orchidea?." 



FOR THE PUBLIC SERVICE IN ENGLAND. 81 

3. What are the most important useful products yielded by the 
natural order Leguminosse ? State the name of each, and the part 
of the plant from which it is obtained. 

4. What are the most important characters of algae, lichens, and 
fungi ? 

5. How do you distinguish between volatile and fixed oils ? By 
what orders of plants are the most important forms of each yielded ? 

PHYSICS. 

1. What is meant by the term specific gravity? Describe the na- 
ture of the processes by which it can be determined in solids, liquids, 
and gases. 

2. Explain the nature of vinous and acetous fermentation. 

3. Explain the terms equator, ecliptic, tropic, latitude, and longi- 
tude, and state the causes of the differences of temperature in the 
northern and southern hemispheres, and in the torrid, temperate, and 
arctic zones. 

4. Explain the causes of the differences of climate on the eastern 
and western coasts of America, Europe, and Asia. 

5. What is the geographical distribution of the chalk formation? 
Give the general characters of its fossils, and explain the mode in 
which it has been formed. 

Preli?ninary examination of candidates for Her Majesty's army, navy, 
and Indian medical services, 1875. 

ANATOMY AND PHYSIOLOGY. 

i. Describe the parts contained in the space circumscribed by four 
lines corresponding with the borders of the masseter muscle, in the 
order in which they are seen in a dissection from the surface'to the 
mesial line. 

2. Give the origin, course, and relations of the profunda ceroids 
artery, and the dissection required to display it on the posterior aspect 
of the vertebras, noticing the parts exposed in the dissection. 

6 N 



82 EDUCATION OF MEDICAL OFFICERS 

3. Name the nerves supplying the following muscles : Obturator 
externus and interims, glutseus maximus, opponens pollicis, supinator 
radii longus, flexor longus digitorum and pollicis. 

4. Describe the mechanism of the heart's action, the sounds attend- 
ing it, and the causes to which they are assigned. 

5. Give a general account of the lymphatic system, including the 
minute structure of the lymphatic vessels and glands. 

6. Point out the distinctive characteristics of the male and female 
pelvis, and state the average dimensions of the outlet in both sexes. 

SURGERY. 

1. Describe the local and general symptoms of acute inflammation 
of the knee-joint, the result of an injury. What changes would occur 
in the external and internal tissues of the joint if the case progressed 
unfavorably? Describe the treatment in each condition. 

2. State the symptoms by which an impacted fracture of the neck 
of the thigh-bone may be distinguished from fracture within the cap- 
sule without impaction, and the treatment in both cases. 

3. What character of tumor is usually found in the region of the 
parotid gland ? Describe its structure and the difficulties in its removal. 

4. State the most frequent causes of suppuration of the internal ear, 
its results and complications, and treatment. 

5. Describe the symptoms by which rheumatic iritis may be distin- 
guished from syphilitic iritis, and the treatment of the latter. 

6. A man has been wounded by a bayonet in the lower third of 
the inside of the thigh, the result of which is recurrent arterial hae- 
morrhage. Describe the treatment to be adopted. 

MEDICINE. 

1. What is meant by the terms pyrexia and hyperexia? How is 
the temperature of the human body best measured? How can the 
high temperature of pyrexia be reduced? 

2. What conditions of the heart may produce anasarca ? Describe 
fully the cardiac physical signs, and give the treatment. 



FOR THE PUBLIC SERVICE IN ENGLAND. 83 

3. How is ascites caused ? Give the treatment in each case. 

4. Give the symptoms and treatment of diabetes mellitus, and state 
what is known of its pathology. 

5. How do you ascertain the existence of pregnancy ? What is 
meant by the term " complicated labor?" How would you treat a 
case of foot-presentation ? 

6. What medicines are supposed to act on the liver, and what are 
the reasons for supposing they do so act ? 

zoology. 

1. Give the characters of the class "fishes," and of the orders into 
which it is divided. 

2. Describe the structure of the sea-urchin and star-fish, and state 
their position in the animal kingdom. 

3. To what order of insects does the ant belong ? Give the char- 
acter of the genus, and describe the economy of an ant-hill. 

4. What is the meaning of the term "alternation of generation"? 
In what animals does it occur? Describe its nature. 

5. What animals have poison-producing organs? Describe their 
position and structure in each case. 

6. Mention some of the animals belonging to the " Cetacea," and 
state what is known of their habits. 

BOTANY. 

1. Give the characters of the natural order "Gramineae," and 
describe accurately the structure of the flower and seed. 

2. What is meant by spontaneous generation, and what are the 
experiments and observations which have been made to prove or dis- 
prove it ? 

3. Give the characters of the genus "Chara." 

4. Explain the terms capsule, berry, drupe, achene, pod, legume, 
follicle, and give examples of each taken from British plants. 

5. What are stipules? In what natural orders do they occur? 

6. Describe some of the plants which are supposed to be nourished 
in part by animal substances as food. 



4 



84 EDUCATION OF MEDICAL OFFICERS 

PHYSICS. 

i. In what form does carbon occur in nature, pure and in compo- 
sition ? 

2. What is the nature and composition of the atmosphere? De- 
scribe and explain the structure of the barometer. 

3. Describe the solar system, and state the relative position of the 
planets, their periods of rotation, and their distances from the sun. 

4. State the modern view of the nature of heat and its relation to 
light. 

5. What is a volcano and what is the distribution of volcanoes on 
the earth's surface? 

6. What is the ultimate origin of the force which moves a tide- 
water mill ? 

The foregoing examples, which are all I could obtain, may serve 
to indicate the character of the first examination which the candi- 
dates are required to pass. It does not seem as rigid or as compre- 
hensive as that for admission into the medical corps of our Navy ; but 
it must be remembered that this examination is in every sense pre- 
liminary, and that success before the board in London does not en- 
title the candidate to any other privilege than that of attending the 
Army Medical School, where he is obliged to remain during an entire 
course of practical instruction of not less than four months before 
being admitted to his examination for his commission. The latter is 
conducted by the professors of the school, and, though confined to 
fewer subjects, is more practical and difficult. As the questions sub- 
mitted at this second examination are prepared by the most distin- 
guished medical officers of the army and navy, and by two physi- 
cians of the highest reputation, Drs. Aitken and Parkes, the exam- 
ples of them which have been forwarded to me from England will 
possess a special value. 



FOR THE PUBLIC SERVICE IN ENGLAND. 85 

Examination of candidates for commission in Her Majesty's army, 
navy, and Indian medical services, at the close of the twenty-eighth 
session of the Army Medical School, Netley, July, 1874. 

MILITARY HYGIENE. 
PROFESSOR E. A. PARKES, M. D., F. R. S. 

1. If you are called upon to examine whether the ventilation and 
the sewerage arrangements of a house are sufficient, to what points 
would you direct your attention ? Full details are required as to 
quantity, movement, and purity of air, and as to examination of 
drains, traps, &c. 

2. What diseases are supposed to be connected with imperfect ven- 
tilation or defective sewerage of houses ? - What are your views as 
to the reality of this connection? 

3. What are supposed to be the physiological influences of climate ? 
And what part do these influences play in the production of dis- 
eases? 

4. What is the usual length of marches for infantry soldiers, and 
what are forced marches ? What are the points to be attended to in 
order that the greatest amount of work may be got out of the soldier with 
the least chance of injury to him ? What are the diseases that may 
attack an army on the march? 

NAVAL HYGIENE. 
STAFF-SURGEON J. D. MACDONALD, R. N., M. D., F. R. S. 

1. Describe the situation of the prison-cells i?i an ordinary ship, stat- 
ing the usual means adopted to secure their ventilation, and the manner 
in which you would inspect them as to their fitness for the reception of 
prisoners. 

2. State also the system on which the magazines are ventilated at 
present, and what improvement you would suggest in respect to it. 

3. Describe the framing of double bottoms in iron ships, stating 
the direction in which currents of air will pass most freely, and how 
their compartments may be efficiently ventilated before workmen 
enter them. 



86 EDUCATION OF MEDICAL OFFICERS 

PATHOLOGY. 
PROFESSOR WILLIAM AITKEN, M. D., F. R. S. 

i. Describe the conditions of the bones of the human skeleton as 
to completeness of ossification from the ages of seventeen to twenty- 
five. 

2. Define (according to the London College of Physicians) the 
term primary syphilis, and name its varieties ; also the terms secondary 
syphilis y tertiary syphilis, and hereditary syphilis. Describe also the 
pathology of the induration of syphilis, and the parts which become 
indurated. 

3. Describe in detail the method of removing the viscera of the 
thorax, and parts therewith connected, as practiced at the post-mor- 
tem examinations; and describe the usual incisions to expose the 
cavities of the heart, stating the reasons for making the incisions in 
the way you describe. 

MILITARY SURGERY. 
SURGEON-GENERAL t. longmore, c. b. 

1. A soldier is wounded in the upper arm by a rifle-shot, and the 
humerus is fractured : 

(a) What conditions of injury would induce you to amputate the 
limb? 

(b) State your reasons for considering amputation necessary under 
the conditions you have named. 

{c) Assuming a case of comminuted gunshot fracture of the hu- 
merus in which you decide to try to save the limb, what will be your 
course of treatment ? 

(d) What serious complications may arise in the course of the treat- 
ment of such a case ? 

2. Answer the same questions as above, but suppose the gunshot 
wound to be in the forearm, and the radius and ulna to be the 
bones fractured. 



FOR THE PUBLIC SERVICE IN ENGLAND. 87 

3. Presbyopia and hypermetropia; explain the difference. A pres- 
byopic patient requires + 24 spectacles to, see clearly small letters 8 
inches from the eye ; where is his point of near vision without spec- 
tacles ? What is hypermetropia equal to t l ? 

MILITARY MEDICINE. 
SURGEON-GENERAL W. C MACLEAN, M. D., C. B. 

i. Give a definition of acute congestion of the liver; contrast it 
with passive congestion, arising from obstruction of the circulation. 
The etiology, symptoms, diagnosis, and treatment of this affection 
are required. 

2. Describe suppurative inflammation of- the liver under the follow- 
ing heads: 

(a) A careful diagnosis between inflammation of the gland and its 
capsule ; 

(J?) The causes which give rise to pysemic abscesses of the gland, 
including symptoms and treatment; 

(c) The etiology of true suppurative inflammation ; 

(d) The symptoms, with a clinical analysis of each ; 

(e) Signs of suppuration, with similar analysis ; 

(/) Number and position of possible abscesses, with the symptoms 
indicative of the position of the different varieties ; 

(g) Points of discharge, indicating those which expose the patient 
to the least danger ; 

(/z) Nature of pus in the different varieties ; 

(z) Condition of the urine before and after suppuration ; 

(k) Treatment. 



SS EDUCATION OF MEDICAL OFFICERS 

Examination of candidates for commission in Her Majesty' 's army, navy, 
and India medical services at the close of the twenty -ninth session of 
the Army Medical School, Netley, February, 1875. 

MILITARY HYGIENE. 
PROF. E. A. PARKES, M. D., F. R. S. 

i. What are the chief causes of contamination of air in houses? 
Mention briefly the modes of preventing the air from the ground and 
from the sewers getting into houses. 

2. What are supposed to be the methods of spread of enteric fever, 
typhus, scarlet fever, and cholera ? And what are the principal 
methods of prevention in each case ? 

3. What part does phthisis play in the mortality of the army at 
home and in India ? What can be done to reduce the mortality ? 

4. What do we mean by climatic diseases and diseases of deterio- 
ration ? Mention the chief conditions favoring the existence of each 
class; and state how far acclimatization seems possible for Europeans 
in India. 

NAVAL HYGIENE. 

DR. J. D. MACDONALD, F. R. S., STAFF-SURGEON R. N. 

i. In case of an epidemic of yellow fever breaking out on board 
ship in the West Indies, what steps would you take — 

(a) To cut short the epidemic ; 

(b) To disinfect the ship ? 

2, Mention the various localities on board ship in which vitiated 
air, and, in particular, the products of respiration and organic impuri- 
ties, chiefly accumulate. 

State also the manner in which the starboard and port watches are 
berthed in their hammocks so as to obviate the effects of overcrowd- 
ing at night. 

PATHOLOGY. 
PROFESSOR WILLIAM AITKEN, M.D., F. R. S. 

1. Describe how the lungs are best prepared for microscopical ex- 
amination. Name the parts and structural elements which are to be 



FOR THE PUBLIC SERVICE IN ENGLAND. 89 

recognized, and the reagents most suitable. Describe the morbid 
structural changes that may be seen microscopically in the lungs. 

2. Name the bones of the skeleton still unfinished, as to growth 
and union of epyphises, at 20 years of age. 
"3. Name the "continued fevers" described as such by the College 
of Physicians. 

4. What is the normal temperature of the body at completely 
sheltered parts, such as the axilla in the closed condition ? What are 
the temperatures which represent "pyrexia" and "hyperexia"? 

5. Describe the lesions in the abdominal viscera in cases of enteric 
fever. 

MILITARY SURGERY. 
SURGEON-GENERAL T. LONGMORE, C. B. 

i. Enumerate the principal varieties of injuries of the head that 
may be inflicted by rifle-shot. Name their distinguishing symptoms, 
and give a short account of the treatment you would pursue in each 
variety. 

2. Give an account of the medical examination of a recruit, par- 
ticularizing all the separate points which have to be attended to in 
the examination. 

3. A soldier is sent by a musketry instructor to a medical officer 
with a statement that the man was found able to aim correctly at rifle 
practice for the first three or four hundred yards, but is unable to aim 
correctly at distances beyond. An opinion is required as to whether 
his eyesight is defective; and, if so, what defect and what amount of 
defect he labors under. 

Describe the steps you would take for answering the inquiry. 

MILITARY MEDICINE. 

SURGEON-GENERAL W. C MACLEAN, M. D., C. B. 

i. What are the precautions necessary to minimize the dangers of 
insolation (a) on the line of march, (b) in barracks, (c) in ships? 
Name the different varieties of this affection, and describe them, 



90 EDUCATION OF MEDICAL OFFICERS 

showing the morbid state resulting from high temperature in the 
blood and tissues, and the most common sequels of insolation; 
and give the most rational treatment of the disease. 

2. What are the most active causes of dysentery in hot climates? 
Describe the disease in its different stages, giving briefly the morbid 
appearances and the most successful treatment; contrast the mortal- 
ity under it with that superseded, adding a short summary of the 
precautions necessary in the management of cases of this disease in 
invalids at sea. 

In addition to the' written examination, the candidate is subjected 
to a practical one in pathology and hygiene, in which he is required 
to analyze samples of milk, beer, wine, water, &c, placed before him, 
and to examine chemically and microscopically portions of tissue, 
and the unknown contents of packets, given him for the purpose. 
He must also describe and delineate the microscopic appearances 
presented. 

The examinations held at the close of each session of the Army 
Medical School, of two of which the examples given are an illus- 
tration, are intended to test the proficiency of the candidates in the 
studies carried on at Netley, and to determine the order in which 
their names will appear for commission. The marks obtained at the 
second examination are added to those of the preliminary examina- 
tion, and the result determines the candidate's place in the list of 
assistant surgeons. 

After five years' service, assistant surgeons are again examined as a 
test for promotion. A series of questions is prepared by the exam- 
ining board, and sent under seal to the principal medical officers of 
stations where assistant surgeons eligible for promotion are serving 
at the time. 

The principal medical officer delivers these sealed questions to the 
assistant surgeons, and sees that they are answered without the assist- 
ance of books, notes, or communication with other persons. The 
answers are signed, sealed, and returned to the principal medical 



FOR THE PUBLIC SERVICE IN ENGLAND. 91 

officer, who sends them, unopened, to the director-general, together 
with a certificate from the surgeon of the regiment that the assistant 
has availed himself of every opportunity to practice surgical opera- 
tions on the cadaver. The assistant is also required to send with 
his answers a medico-topographical account of his station, or a 
medico-statistical report of his regiment, for a period of one year. 
If the answers, certificates, and reports are considered satisfactory by 
the examining board and by the director-general, the assistant is pro- 
nounced qualified for promotion. 

It thus appears that the medical officers of the army and navy in 
England are required to pass three examinations. . The first or pre- 
liminary is " to ascertain, previous to his admission into the service 
as a candidate, his scientific and professional education. The second, 
after having passed through a course of special instruction in the 
Army Medical School at Netley, is to test his knowledge of his spe- 
cial duties as an army or navy medical officer; and the third, pre- 
vious to his promotion, to ascertain that he has kept pace with the 
progress of medical science." — (Sydney Herbert.) 

It has been my object to give in this report, I fear at the risk of 
some prolixity, a complete and detailed account of the systems of 
education for medical officers of the army and navy, adopted by 
Prance and England — two great and enlightened nations. Occupy- 
ing, as they do, a foremost place among the mighty powers of 
Europe, and ever vying with each other in the improvement of their 
formidable military and naval forces, it is fair to assume that what- 
ever they have done in this direction has been the result of the les- 
sons of experience and of a well-grounded conviction of its utility. 

It has been seen that in the former country during an entire cen- 
tury, though the land has been convulsed with revolutions which 
have overthrown almost all other institutions at one time or another, 
the naval medical schools in her great ports have been preserved 
through every changing dynasty; and that monarchy, empire, and 
republic have alike cherished them, and recognized the fact that they 



92 EDUCATION OF MEDICAL OFFICERS 

gave vital help to the state as well as lustre to the fame of France. 
Some of the greatest names that adorn the annals of medicine are 
found to be those of men educated at these schools ; and, in the skill- 
ful surgeons and learned savants they have furnished, the government 
has been repaid tenfold for its outlay. 

And in our own noble mother country, fettered as she is by a na- 
tional conservatism which binds her back from any forward move- 
ment, until it has been duly weighed and considered, a similar insti- 
tution has been found a necessity which could no longer be dispensed 
with, and its establishment has all the more significance now that it 
is finally adopted. 

Both these nations have sought through these schools to mitigate, 
as much as possible, the evils which war and disease bring on their 
people, and to keep their forces efficient and promptly available by 
land and sea. The two systems having the same object, yet differ 
from each other as widely as the character of the two nations, and 
it may be to our advantage to view them in comparison. 

That of France is much older and longer established, having been 
organized considerably more than a hundred years ago ; while that 
of England was inaugurated as recently as i860. The former is, 
therefore, naturally more extended and complete ; there being in 
France the three naval medical schools of Brest, Rochefort, and 
Toulon, and the army medical school at Val-de-Grace in addition,, 
whereas in England there is but one school in common for the med- 
ical corps of the army, navy, and Indian services. 

The French system is more liberal, as the state takes charge of the 
entire medical education of the candidate, supplying to him the ru- 
dimentary professional instruction as well as the more advanced, and, 
after giving him the advantages of gratuitous teaching for two years, 
sends him, at the public expense, to one of the great universities, at 
Paris or Montpellier, which are authorized to confer diplomas, and 
defrays all the cost of procuring his degree, and continues afterward 



FOR THE PUBLIC SERVICE IN ENGLAND. 93 

to afford him every facility for qualifying himself for promotion from 
grade to grade. 

In England, on the other hand, no assistance is extended to any 
candidate by the government until he first, at his own expense, has 
obtained a medical education, taken a diploma, and successfully 
competed before an examining board for appointment to the army 
medical school, where he receives a supplementary and practical 
education only. 

In France, all examinations of candidates are conducted by medi- 
cal officers of the army and navy ; but, in England, the first examina- 
tion for admission into the service, and that for promotion afterward, 
are conducted by a board the members of which have no connec- 
tion with military life. 

Finally, in France, the medical officer is examined for promotion 
to every grade, and cannot obtain his advancement until he proves 
himself qualified ; while in England the assistant surgeons are exam- 
ined once for promotion to all grades. 

But, while the government of France bestows its favors with a 
more liberal hand, it also requires more in return, and exacts from 
the recipient of its bounty a pledge of prolonged service, and, should 
he voluntarily withdraw from the obligation imposed on him, requires 
restitution of the outlay expended on him. Indeed, it is evident that 
without some such guarantee no government would find it to its in- 
terest to undergo such a great expenditure. 

As to the relative value of the instruction received, I am inclined 
to believe that perhaps that obtained at Netley is more directly 
practical, and attains in a more complete manner its special object, 
that of training the candidate in the actual duties of his prospective 
position. 

It is more limited in the subjects embraced, but it is well adapted 
to its purpose, and, like most things in England, is marked by the 
absence of non-essentials, by solid and substantial utility, and unos- 
tentatious thoroughness. 



94 EDUCATION OF MEDICAL OFFICERS. 

Still it must be conceded that the teaching in France is also most 
able, comprehensive, and useful, and it would seem to be easier in 
this, as in other instances, to contrast than to compare the different 
methods used to gain the same end by these two remarkable nations. 

It is a thing that ought to fix our attention, however, that the ear- 
liest efforts to establish schools to give special training to army and 
navy surgeons, both in England and in France, arose from the obser- 
vation that the medical officers were but imperfectly qualified for the 
wide range of duties required of them in great emergencies. 

Dr. John Bell visiting the hospitals at Yarmouth after the battle 
of Camperdown, and M. Dupuy at Rochefort, when that port was 
crowded with sick and wounded after some of the engagements under 
Colbert, both declared such institutions necessary on the same ground, 
that the surgeons lacked the special training necessary to the perfect 
performance of their high functions. 

Would a similar inquiry in relation to oar service reveal a like state of 
affairs ? 

Perhaps this is a question which every medical officer can best 
answer for himself, and I would not do the medical corps of the Navy 
the injustice to affirm that it would, in a general sense. At the same 
time, I know no reason why the members of our service should be 
considered more intelligent, more devoted, or more zealous than our 
colleagues in England and France, and it was true of them. I for one 
am not ashamed to declare that I believe a special training in the schools 
of either England or France would greatly enhance the value of my 
services to the Government, both in peace and war. Moreover, 
knowing all that I do of the three services, I deem it my duty to say, 
in concluding this report, that such a school would be of immense 
advantage to the Navy of the United States, and that the absence of 
any such place of special training for the service is a defect that can 
not be remedied too soon. 



LEAp'09 



